Download Sorting out the Patient Data Base

Sorting out the Patient Data Base
Helen T. Ocdol, M.D., F.P.C.P., F.P.S.N.
Clinical Integration
June 16, 2009
Sorting Out the Data Base
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History
Physical Examination
Salient Features
Differential Diagnoses
Impression
Pathophysiology of the signs and symptoms
Appropriate diagnostic work-up
Systematic Plan of Management
Prognosis
History
• General Data – sex, age (DOB), address, reliability
• Chief Complaint – sign/symptom/finding
• History of the Present Illness – attributes/work-up/Rx
- may include allergies/drug reaction
• Review of Systems
• Past History – when/age at occurrence
Childhood illnesses/vaccination
Medical – illnesses, hospitalizations, medications
Surgical – operations/complications
• Personal and Social History
• Family History
Salient Features
• Subjective - history
• Objective – physical exam/diagnostic work-up
 Pertinent positives
 Pertinent negatives
Differential Diagnoses
• Pivot – sign or symptom
ex: epigastric pain – causes/location/associated SSx
lab test result/diagnostic work-up result
ex: elevated uric acid – causes
• Reasons why you are considering this disease
- based on your salient features
• Reasons why you are ruling out the disease
– based on the salient features
Approaching the challenges of clinical data
• Clustering Data into single versus multiple problems
ex: age – young versus the elderly
timing of symptoms – nature of the different disease
involvement of different body systems
• Sifting through an extensive array of data – tease out
separate clusters of observations and analyze one cluster at
a time – ask questions
• Assessing the quality of the data - misinterpret patient’s
statements, overlook information, fail to ask key
questions, jump prematurely to conclusion and diagnosis,
or forget an important part of the examination
How do you ensure the quality of the data?
• Ask open-ended questions and listen carefully and
patiently to the patient’s story
• Craft a thorough and systematic sequence to history
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taking and physical examination
Keep an open mind toward both the patient and the data
Always include “the worst scenario” in your list of possible
explanation of the patient’s problems and ensure that
it can be eliminated
Analyze any mistakes in data collection or interpretation
Confer with colleagues and review the pertinent medical
literature to clarify uncertainties
– Apply principles of data analysis to patient information and
testing
Clinical Impression/Diagnosis
• Expound on the impression
- how you arrive at the diagnosis based on the
salient features
- any diagnostic work-up needed to further clinch the
diagnosis can be mentioned
Pathophysiology
• Explain the signs and symptoms manifested by your patient
ex: cough – lung versus cardiac pathology
drug use – manifestation
Diagnostic Plan
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Laboratory tests – blood, urine and other body fluids, stool
Biopsy - histopathology
Radiologic
Nuclear
 Sensitivity/Specificity of the test
 Positive or negative predictive value
 Pre- and Post-test probability of having the disease if the
test turns out to be positive/negative
 Likelihood ratio can be computed if there is no value available
for the post-test probability
Therapeutic Plan
• Non-pharmacologic treatment
lifestyle changes – diet, exercise,
cigarette/alcohol/drug abuse cessation
• Pharmacologic – medications
dose
preparation
route
frequency
duration
side effects/allergies
Prognosis
• Progression of the disease
Ex: Renal – stage of the disease
• Life expectancy with the proposed treatment
or without treatment
References
• Books
• Journal articles
• Up-to-date
 Avoid using on-line references
Written reports
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Comprehensive Adult Health History
Physical examination
Salient features
Problem List
Assessment/Differential diagnosis
Impression/Diagnosis
Pathophysiology of the signs and symptoms
Plan: Diagnostic work-up /Management
Comprehensive Adult Health History
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Identifying data
Reliability
Chief Complaint
History of the present illness
Past history
Family History
Personal and Social History
Review of System
The Adult Health History
• Identifying date – age, gender, occupation, marital status,
religion
• Reliability – depends on patient’s memory, trust & mood
• Chief Complaint(s) – reason for seeking the doctor
• Present Illness – amplify the chief complaint
- may include pertinent medications, allergies, habits
• Past History – childhood illnesses, medical, surgical, OBGyne, psychiatric history
• Family History – illnesses and death with reason, age
• Personal and Social History – education, household,
- interests, lifestyle
• Review of Systems – presence or absence of common
symptoms related to each major body system
INFORMANT AND RELIABILITY
• Identify the informant
• Sources of information for the history:
- previous medical record
- referral letter from a previous doctor
• Description of the reliability of the informant:
- “the patient is vague when describing
symptoms
and cannot specify details.”
Percent reliability will not be used
HISTORY OF THE PRESENT ILLNESS
• Narrative or story regarding the patient’s chief
complaint
• Although the data flow spontaneously from the
patient, the task of organization and the filtering
and proper selection of information belongs to
the historian
• Chronology of symptoms and their progression of
symptoms is emphasized.
• All information pertinent to the present illness
should be placed initially in the history
HISTORY OF THE PRESENT ILLNESS
• All other information contributory to the present
complaint can follow:
-Signs and symptoms that occurred in the past
but related to the present history
-Any pertinent past history
• More than one complaint or concern, each merits
its own paragraph and a full description
• Include patient’s feelings, perception and thoughts
about the illness
• This information is crucial to patient satisfaction,
effective health care and patient follow-though
Examples
• A patient with long-standing diabetes is
admitted for stroke, start with events leading
to it and then summarize the past history of
the patient’s diabetes.
• “For about 3 months, the patient has had
increasing problems with frontal headache...
Her headache with nausea and vomiting
began at
age 16, recurring throughout
her mid-20’s...”
Exploring the patient’s perspective
(6 domains)
• Thoughts about the nature and cause of the
problem
• Feelings, especially fears, about the problem
• Patient’s expectations of the clinician and health
care
• Effect of the problem on the patient’s life
• Prior personal or family experiences that are
similar
• Therapeutic approaches the patient has already
tried
REVIEW OF SYSTEMS
• Questions may uncover problems that the patient
has overlooked, particularly in areas unrelated to
the present illness
• Further description of additional symptoms may
be necessary
• Done by organ system but avoid “checklist”
questioning
• Avoid using “see HPI” or “Non-contributory”
• Include only symptoms applicable to the
patient’s age, general state of health and the
historian’s clinical judgment – particularly in
critically ill patients
PERSONAL/SOCIAL HISTORY
• Seek concerns that are applicable to the
patient and his condition – source of support,
coping style, lifestyle habits, safety measures,
alternative health care practices
• Ex: water source and number of household or
family members may be relevant for typhoid
fever
Physical Examination
• Bates’ will be our standard reference
• Always report in the present tense
PHYSICAL EXAMINATION
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General Survey
Vital Signs
Skin
Head and Neck
Chest /Thorax and Lungs
Breasts
Cardiovascular
Abdomen
Musculoskeletal/Extremities
Genitalia/Rectal
Neurologic
SALIENT FEATURES
• Cluster patient information and apply clinical
reasoning
• Interpretation of the findings
• Must include pertinent positives and negatives
that will lead to the differentials and justify
diagnosis
• Both subjective and objective information make
up the core elements of your observations –
information is primarily factual and descriptive
PROBLEM LIST
• Should be ranked from most to least
important decided on by the physician
• Organize or cluster data pertaining to one
problem
• Resolved problems must not be put in the
problem list, but instead include in the past
history
ASSESSMENT
• Different from diagnosis
• Go beyond description and observation to analysis and
interpretation
• Select and cluster relevant data, analyze meanings and
try to explain them logically using principles of
biopsychosocial and biomedical science
• Historian commits to a diagnosis and provide insight
into your reasoning
• If unsure of your diagnosis, you should still commit to
what you think is the most likely and why
• Generate as broad a differential diagnosis for each
problem
ASSESSMENT
• Use evidence-based medicine
• Ex: The sensitivity fo the Homan’s sign in the
diagnosis of deep venous thrombosis (DVT)of the
calf is 50%. So this sign, if absent, may not be
helpful because 50% of patients may still have
DVT.
• Take one problem at a time based on the
problem list – “problem-oriented medical
diagnosis”
• Prognosis should be included
ASSESSMENT (Example)
• A 52-year-old woman has migraine headaches since
childhood, with throbbing vascular pattern and frequent
nausea and vomiting. Headaches are associated with
stress and relieved by sleep and cold compresses. There
is no papilledema and there are no motor or sensory
deficits on the neurologic examination. The differential
diagnosis includes tension headache, also associated
with stress, but there is no relief with massage, and the
pain is more throbbing than aching. There are no fever ,
stiff neck, or focal finding to suggest miningitis, and the
lifelong recurrent pattern make subarachnoid
hemorrhage unlikely (usually described as “the worst
headache of my life”
DIFFERENTIAL DIAGNOSIS
• Can be summarized also under assessment
• Include entities that are seriously being
considered
• Refrain from listing all causes of a symptom,
syndrome or abnormal lab result
• The reasons which make the differentials less
likely should be stated
PATHOPHYSIOLOGY
• Correlate the signs and symptoms of the
patient with the clinical impression – may
include lab result
• Explain the occurence of the sign or symptom
of the patient to the diagnosis
• Focused discussion on the patient
• DO NOT COPY/ PASTE
Plan
• Focused on the patient
• Do not copy/paste
• Refrain from using algorithm and discussions
from the textbook
• Difference between Plan from the Chart Order
• Comprehensive rather than a list of tests and
medications
• Include long-term and follow-up plans for the
patient
• Discuss complications and controversies in the
management
• The history and physical examination should
be the patient’s “story” from the perspective
of the clinician.
• Medically sound and logical written report
• A good write-up should enable the next
physician who would evaluate the patient to
have a clear and precise picture of the patient,
along with a complete understanding of all the
patient’s problems, even without him having
seen the patient
• A good write-up should enable the next
physician who would evaluate the patient to
have a clear and precise picture of the patient,
along with a complete understanding of all the
patient’s problems, even without him having
seen the patient
Have a great 3rd year!