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Secrets of Expert Clinicians: Schemes/Cognitive Aids for Decision Making
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Secrets of Expert Clinicians: Schemes/Cognitive Aids for Decision Making

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Schemes for Decision Making

Schemes for Decision Making

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  • 1. Table 1: The 7 Expert Clinician’s Actions Map for a Patient Encounter and their Cognitive Schemes Step Clinical Action 1 Gather Information (History & Physical) 2 Summarize the Case using Technical Language 3 Propose a Diagnosis Expert ‘s Scheme/Cognitive Aid ------------------------ Comprehensive but Concise, Textbook-Like: Must contain patient’s name, gender, age, ±occupation, ±nationality ± racial/geographic origin, relevant Past History/Social History/Family History, Drug/Allergic History, Symptoms + duration –in technical terms, Relevant physical signs in technical conclusive terms. Patternrecognition PR, Hypotheticodeductive Strategies HD (from H&P) and Smart Heuristics (Rules-of-Thumb), Rule-Out worst Scenario ROWS, Red Flags (symptoms or signs of more serious pathology) etc. The 3Rs! Example --------------------------------------------------------------------------67 yr old male Bird/pigeon breeder, smoker 3 days history of fever, cough with yellow sputum, left stabbing chest pain that is worse with breathing and coughing and breathlessness Clinically, breathless, cyanosed, disoriented to time, person and place, Temperature 39.1C, BP 86/50, RR 32/min, bilateral coarse crepitations, bronchial breathing left lower zone Chest x-ray: left basal consolidation Summary: 67 year old, smoker and bird-breeder presenting with a 3 days history of productive cough, dyspnea and left pleuritic chest pains. Clinically confused, cyanosed, febrile, tachypnoiec and hypotensive with signs of left lower zone consolidation. High-Fidelity/Reliability Pattern Recognition (spot diagnosis): Shingles, Acromegalic Facies Low-Fidelity/Reliability Pattern Recognition (error-prone): Central chest pain radiating to the left arm plus sweating=ACS (other possibilities still exist!) Smart Heuristic “Rules of Thumb”: early morning headache and vomiting=Increased intracranial pressure ROWS: Meningitis, SAH, CVA etc in a patient with headache Red Flags: rest pain, weight loss, neurological deficits etc in a patient with low back pain
  • 2. 4 Differential Diagnosis Differential Diagnosis Cognitive Aids: Anatomical, Physiological, Pathological Anatomical: Swellings, Pain, Amenorrhea Physiological: Shock, Thrombosis, Hyponatremia Pathological: Traumatic, Infective, Inflammatory/auto-immune, Vascular/degenerative, Neoplastic/paraneoplastic, Metabolic/endocrine, Druginduced/poisoning, Deficiency diseases, Psychogenic and Idiopathic/cryptogenic. 5 Order Tests (Rationally) Frugal(simple and applicable) Heuristics Probability Assessment, Order tests: Test Sensitivity, Specificity and Likelihood Ratios Pre-test Probability: 1. Strong Risk factor for the condition 2. No alternative Diagnosis High (2 YES) or Intermediate (1 YES 1 NO) or Low (2 NO) SpIn: highly specific tests are useful for ruling-in the diagnosis when positive ( use for high and intermediate probabilities) SnOut: highly sensitive tests are useful for ruling-out the diagnosis when negative ( use for low probabilities) 6 Confirm & Comprehensively give a Diagnostic Label Bed-side Diagnosis: CAP Etiology: Chlamydia psittaci Severity: CURB-65= 4 7 Therapeutic Interventions 8 Prepare for Discharge Guideline-friendly Bed-side Diagnosis, Etiology, Severity (BESD) Contextual, Patient-centered Therapeutic Cognitive Aid: Site of Care, Symptomatic, Supportive, Specific and Specialty Referral (5S). Assess Response to Treatment (Subjective & Objective), Criteria for Discharge, Timing of Followup (ACT) Site of Care: Ward, CCU, ICU etc Symptomatic: Analgesia, Anti-emetic, Antipyretic etc Supportive: Oxygen, IV fluids, Bicarbonate etc Specific: Antibiotic, Thrombolytic, Cytotoxic etc Specialty Referral: Cardiology, Surgery, Gynecology, Physiotherapy etc Assess Response to Treatment : Subjective & Objective Criteria for Discharge: Clinical, Laboratory, Radiologic, Social etc Timing of Follow-up : Clinic Appointment for disease and drug monitoring
  • 3. Box 1: Summarizing the History and Physical Examination Comprehensive but Concise, Text-book-Like: Must contain patient’s name, gender, age, ±occupation, ±nationality ± racial/geographic origin, relevant Past History/Social History/Family History, Drug/Allergic History, Symptoms + duration –in technical terms, Relevant physical signs in technical conclusive terms. Table 2: Differential Diagnosis Cognitive Aids Anatomical Differential Diagnosis Pain Syndromes: e.g. central chest pain may be categorized as arising from the heart, aorta, esophagus, chest wall etc Swellings: e.g. a neck swelling differential diagnosis will include the thyroid, lymph nodes, vascular, skin etc Physiological Differential Diagnosis Shock: this may be hypovolemic, distributive, obstructive or cardiogenic Etio-pathological Differential Diagnosis Congenital or Hereditary Thrombosis: This may be related to a vessel wall pathology, blood constituents or flow rate. Acquired: 1. Traumatic 2. Infective: viral, bacterial etc 3. Inflammatory/autoimmune 4. Vascular/degenerative 5. Neoplastic/paraneoplastic 6. Metabolic/endocrine 7. Drug-induced/ poisoning 8. Deficiency diseases 9. Psychogenic 10. Idiopathic/cryptogenic
  • 4. Table 3: Sensitivity, Specificity and Likelihood Ratios: Definitions and Examples Sensitivity SENSITIVITY How often is the test result correct for persons in whom the disease is known to be present? Sensitivity - the proportion of people with disease who have a positive test. Example: in a group of 100 patients with bacterial pneumonia, 80 had a raised C-reactive protein CRP: the sensitivity of CRP for diagnosing bacterial pneumonia is thus 80%. Specificity SPECIFICITY How often is the test result correct for persons in whom the disease is known to be absent? Specificity - the proportion of people without the disease who have a negative test. Example: in a group of 100 patients without pneumonia, 10 had a raised C-reactive protein CRP: the specificity of CRP for correctly excluding pneumonia is thus 90%. Likelihood Ratio Likelihood ratio: the likelihood that a given test result would be expected in a patient with the target disorder compared to the likelihood that the same result would be expected in a patient without that disorder. In general, a positive likelihood ratio of 4 or more is useful in ruling-in the target disorder. A negative likelihood ratio of less than 0.3 is useful in ruling-out the target disorder. Example: A raised Jugular venous pressure JVP in a patient with a history suggestive of congestive heart failure CHF has a positive LR of 5.8 and a negative ratio of 0.66. Thus the presence of a raised JVP rules-in the diagnosis of CHF. Its absence is not as useful in ruling it out.