An article on a practical road map for teaching trainees easy schemes for Clinical Decision Making. Due to appear soon on the journal "Perspectives on Medical Education"
Useful for Trainers and Trainees alike to complement and expand the PowerPoint presentation on the same subject.
This document discusses clinical decision making for paramedics. It covers topics such as paramedics serving as prehospital medical practitioners, life-threatening patient conditions, protocols and standing orders, the critical thinking process, and the "Six R's" method for assessment and treatment. Paramedics must make critical decisions in emergency situations by gathering information, developing diagnoses, and using their medical knowledge and experience. They must also consider patient acuity, follow treatment guidelines, and continually re-evaluate patients.
The document discusses clinical decision making in evaluating and treating patients. It involves gathering subjective and objective data from patients, determining appropriate goals and treatment plans based on evaluation findings and clinical judgment, monitoring patient progress, and determining discharge. Treatment plans are adjusted based on a patient's response. Frequent re-evaluations ensure treatment strategies remain appropriate.
Experience of Vascular Interventional Procedures of Adana Numune Research and...ijtsrd
Objective The aim of this study was to analyze our experiences of interventional procedures for diagnosis and treatment. Methods This study was performed retrospective between January 2016 and June 2016. 38 patients were included in this study in Neurology clinic of Adana Numune Research and Training Hospital. Results The mean age of the patients was 58.6. A number of males were 19. A number of females were 19. 21 55.3 of the patients underwent diagnostic angiography, 6 15.8 underwent stenting and 11 28.9 underwent thrombectomy or endovascular coiling operation. Conclusions The use of interventional neurological procedures is increasing. Interventional neurological procedures are very risky. But diagnosis and treatment options are very beneficial for well-selected patient groups. Experienced experts are needed. Investments should be made for the progression of neuro endovascular therapies in our country. Abdurrahman Sönmezler | Semih Giray "Experience of Vascular Interventional Procedures of Adana Numune Research and Training Hospital" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-3 | Issue-2 , February 2019, URL: https://www.ijtsrd.com/papers/ijtsrd21597.pdf
Paper URL: https://www.ijtsrd.com/medicine/other/21597/experience-of-vascular-interventional-procedures-of-adana-numune-research-and-training-hospital/abdurrahman-s%C3%B6nmezler
Informed consent is required for any medical procedure and involves educating the patient on the nature, risks, and benefits of the procedure. Key aspects of informed consent include voluntary agreement from the patient, disclosure of relevant medical information, and the patient's competence to consent. Exceptions may apply in emergencies or for therapeutic reasons. Standards for obtaining informed consent aim to respect patient autonomy while balancing ethical obligations of beneficence.
Crisis resource management (CRM) is an approach adapted from aviation that focuses on human factors and team performance to improve patient safety. CRM training teaches skills like situational awareness, communication, leadership, and teamwork. Through simulation-based exercises, it aims to address known human errors like fixation, poor communication, and workload issues. Implementing CRM training has been shown to improve outcomes like provider satisfaction, safety culture, clinical performance, and decreased errors and complications.
This document provides guidance on presenting long cases for clinical examinations. It emphasizes preparing a concise yet comprehensive summary, developing a differential diagnosis, and outlining a management plan using recognized frameworks. Specifically, it recommends including the patient's name, demographic details, history of present and past illness, relevant physical exam findings, and a concluding statement using medical terminology in the summary. Differential diagnoses should consider anatomical, physiological and etiological possibilities. Investigation and treatment of acute and chronic problems should be addressed separately using headings for the "5S" scheme of site of care, symptomatic relief, supportive care, specific treatment, and any needed specialty referrals. Discharge planning involves assessing response to therapy and social/follow-up needs. Practicing
The document discusses a practice advisory for preanesthesia evaluation published by the American Society of Anesthesiologists. It defines preanesthesia evaluation as the clinical assessment process performed before anesthesia care for surgery or other procedures. The evaluation involves considering information from medical records, interviews, exams, and tests to inform perioperative care planning. The purposes of the advisory are to assess evidence on the healthcare benefits of preanesthesia evaluation and provide a framework to guide anesthesiologists in conducting evaluations.
This document discusses clinical decision making for paramedics. It covers topics such as paramedics serving as prehospital medical practitioners, life-threatening patient conditions, protocols and standing orders, the critical thinking process, and the "Six R's" method for assessment and treatment. Paramedics must make critical decisions in emergency situations by gathering information, developing diagnoses, and using their medical knowledge and experience. They must also consider patient acuity, follow treatment guidelines, and continually re-evaluate patients.
The document discusses clinical decision making in evaluating and treating patients. It involves gathering subjective and objective data from patients, determining appropriate goals and treatment plans based on evaluation findings and clinical judgment, monitoring patient progress, and determining discharge. Treatment plans are adjusted based on a patient's response. Frequent re-evaluations ensure treatment strategies remain appropriate.
Experience of Vascular Interventional Procedures of Adana Numune Research and...ijtsrd
Objective The aim of this study was to analyze our experiences of interventional procedures for diagnosis and treatment. Methods This study was performed retrospective between January 2016 and June 2016. 38 patients were included in this study in Neurology clinic of Adana Numune Research and Training Hospital. Results The mean age of the patients was 58.6. A number of males were 19. A number of females were 19. 21 55.3 of the patients underwent diagnostic angiography, 6 15.8 underwent stenting and 11 28.9 underwent thrombectomy or endovascular coiling operation. Conclusions The use of interventional neurological procedures is increasing. Interventional neurological procedures are very risky. But diagnosis and treatment options are very beneficial for well-selected patient groups. Experienced experts are needed. Investments should be made for the progression of neuro endovascular therapies in our country. Abdurrahman Sönmezler | Semih Giray "Experience of Vascular Interventional Procedures of Adana Numune Research and Training Hospital" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-3 | Issue-2 , February 2019, URL: https://www.ijtsrd.com/papers/ijtsrd21597.pdf
Paper URL: https://www.ijtsrd.com/medicine/other/21597/experience-of-vascular-interventional-procedures-of-adana-numune-research-and-training-hospital/abdurrahman-s%C3%B6nmezler
Informed consent is required for any medical procedure and involves educating the patient on the nature, risks, and benefits of the procedure. Key aspects of informed consent include voluntary agreement from the patient, disclosure of relevant medical information, and the patient's competence to consent. Exceptions may apply in emergencies or for therapeutic reasons. Standards for obtaining informed consent aim to respect patient autonomy while balancing ethical obligations of beneficence.
Crisis resource management (CRM) is an approach adapted from aviation that focuses on human factors and team performance to improve patient safety. CRM training teaches skills like situational awareness, communication, leadership, and teamwork. Through simulation-based exercises, it aims to address known human errors like fixation, poor communication, and workload issues. Implementing CRM training has been shown to improve outcomes like provider satisfaction, safety culture, clinical performance, and decreased errors and complications.
This document provides guidance on presenting long cases for clinical examinations. It emphasizes preparing a concise yet comprehensive summary, developing a differential diagnosis, and outlining a management plan using recognized frameworks. Specifically, it recommends including the patient's name, demographic details, history of present and past illness, relevant physical exam findings, and a concluding statement using medical terminology in the summary. Differential diagnoses should consider anatomical, physiological and etiological possibilities. Investigation and treatment of acute and chronic problems should be addressed separately using headings for the "5S" scheme of site of care, symptomatic relief, supportive care, specific treatment, and any needed specialty referrals. Discharge planning involves assessing response to therapy and social/follow-up needs. Practicing
The document discusses a practice advisory for preanesthesia evaluation published by the American Society of Anesthesiologists. It defines preanesthesia evaluation as the clinical assessment process performed before anesthesia care for surgery or other procedures. The evaluation involves considering information from medical records, interviews, exams, and tests to inform perioperative care planning. The purposes of the advisory are to assess evidence on the healthcare benefits of preanesthesia evaluation and provide a framework to guide anesthesiologists in conducting evaluations.
An expert discusses strategies for implementing a good academic emergency medicine training program. Key aspects include:
- Strong selection process and induction training to prepare students.
- Focused clinical rotations, electives, life support courses, procedures, and skills training to build proficiency.
- Daily teaching, case discussions, bedside learning and faculty coverage to mentor students.
- Evaluations, research, workshops and conferences to assess progress and support continued learning.
- Exit exams to ensure students have achieved expected competencies before completing the program.
This document discusses clinical audits in anaesthesia. It defines clinical audits as quality improvement processes that systematically review care against criteria to improve outcomes. The document outlines the history of audits dating back to Florence Nightingale. It describes different types of audits including clinical, critical event, outcome, training, and survey audits. The audit cycle is also explained as preparing criteria, measuring performance, implementing improvements, and sustaining changes. Barriers to audits are a lack of resources, expertise, and leadership. Audits aim to improve standards but challenges include support, time constraints, and obtaining consent.
- The POINT trial investigated whether clopidogrel plus aspirin reduces new ischemic vascular events compared to placebo plus aspirin in patients with minor stroke or high-risk TIA treated within 12 hours.
- Over 4,800 patients from 269 sites in 10 countries were randomly assigned to clopidogrel+aspirin or placebo+aspirin. Patients receiving clopidogrel had a 25% lower risk of stroke or other ischemic events but a higher risk of major bleeding.
- The trial was stopped early due to a safety signal of increased major hemorrhage in the clopidogrel group. However, clopidogrel was found to provide benefit for ischemic outcomes within the first 3 weeks
This document discusses observation units in emergency departments. It begins with introducing observation units and their objectives, then discusses the rationale and design features of such units. Key points covered include having clearly defined policies and staffing, focusing on conditions that can be better managed over a longer period of time than a traditional emergency department visit allows. The document also outlines potential pros and cons, as well as evidence from studies showing observation units can provide faster, better, cheaper care for certain patients.
The document discusses patient-centered outcomes for perioperative research. It proposes "disability-free survival" as a new outcome measure that is meaningful to patients. Disability-free survival combines survival rates with a validated patient-reported assessment of disability. The authors validate a short version of the World Health Organization Disability Assessment Schedule (WHODAS) for use in surgical patients. Widespread use of disability-free survival could improve shared decision making, quality metrics, and benchmarking by focusing on outcomes that matter to patients rather than surrogate outcomes or doctor perceptions of success.
Supratentorial intracerebral hemorrhage volume and other CT variables predict...NeurOptics, Inc.
However, it is not practical to obtain repeated serial CT scans in ICH patients to assess for these factors. A noninvasive indicator method of assessing the aforementioned factors would be very useful and could serve as a trigger for repeating a CT scan in a patient with ICH.
Decide treatment - a new approach to better healthØystein Eiring
Better treatment, better health! People often experience suboptimal health because treatment is not optimal. A new approach is being developed - enabling patients and doctors to improve treatment and improve health.
Contributing factors to patients overcrowding in emergency department at king...Alexander Decker
This document summarizes a study that explored factors contributing to patient overcrowding in the emergency department at King Saud Hospital in Unaizah, Saudi Arabia. The study found that the main factors were a lack of human resources, high population density, lack of beds, issues with public health awareness, and problems with emergency department design. A survey of 168 medical professionals at the hospital identified health awareness as having the highest impact and lack of beds as having the lowest impact on emergency department overcrowding. The study recommends strategies like increasing staffing levels and space in the emergency department.
Wijeysundera et al-2015-anesthesia_&_analgesiasamirsharshar
- The study found that patients managed by high-performing anesthesiologists experienced rates of postoperative death or major complications that were 45% lower than rates among patients managed by low-performing anesthesiologists.
- This confirms an implicit understanding among anesthesiologists that individual skill and performance varies, and that choice of anesthesiologist can impact patient outcomes, especially during complex high-risk procedures.
- Further research is needed to identify factors that explain variations in performance, such as procedure volume, and to leverage variations to identify best perioperative practices.
Virtual Reality Reflection Therapy Improves Balance and Gait in Patients with...Avi Dey
Technology enhanced version of Mirror Box Therapy called Virtual reality reflection therapy (VRRT) . Taesung In Et Al, (Department of Physical Therapy, College of Health Science, Sahmyook University, Seoul, South Korea) . Referred by Café Twin, Fairfax, VA USA. (LinkedIn.com/Café Twin) 2016
The document discusses trauma teams and their roles. It defines a trauma team as a multidisciplinary group that works together to assess and treat severely injured patients. A team approach has been shown to significantly reduce resuscitation times compared to individual doctors. The roles of trauma team members are outlined, as well as techniques for effective communication, briefing, handover, and speaking up if concerns arise. Statistics from Western Australia in 2015 show the most common causes of death for major trauma patients were head injuries and brain death. Overall mortality rates were lower than the national average.
The document discusses optimizing the use of atypical antipsychotics by reducing variability in patient care and outcomes. It outlines a four-step optimal care process: 1) making a proper diagnosis and communicating it to the patient, 2) considering acute symptom control and long-term goals in medication initiation, 3) adjusting treatment to achieve stability, and 4) maintaining care to minimize relapse. Barriers to optimal care are identified along with expert approaches to address them at each step of the care process.
Brain Health: The Importance of Recognizing Cognitive Impairment: An IAGG Con...Nutricia
This document summarizes the conclusions of an expert panel convened by the International Association of Gerontology and Geriatrics to discuss early detection of cognitive impairment. The panel agreed that:
1) Validated screening tests that take 3 to 7 minutes can identify early cognitive impairment.
2) The most effective approach is to use both patient-reported and informant-reported screening tools.
3) Early cognitive impairment may have treatable components, and emerging evidence supports interventions like medical treatment, nutrition changes, and physical/cognitive exercise to delay or reduce decline.
This document provides a practical protocol for using mirror therapy in stroke rehabilitation. It begins with an introduction to mirror therapy and its aims. Chapter I discusses general requirements for its use, including suitable patient characteristics, treatment aims, environment/materials needed, and treatment characteristics. Chapter II will describe the first therapy session in detail.
This document provides clinical care guidelines for the management of children presenting with symptoms or signs of acute encephalitis syndrome, with a focus on Japanese encephalitis. It was created by an international working group including experts from WHO, PATH, universities, and other organizations working on Japanese encephalitis. The guidelines are intended to guide the assessment and management of acutely ill children, especially those with fever, altered mental status, seizures, or other symptoms suggesting meningitis or encephalitis. They promote evidence-based and syndromic approaches to support rational and affordable therapy. The guidelines also discuss potential complications, medications, and include appendices with tools to aid assessment and management. Facilities should adapt the guidelines based on local illnesses,
Application of Management Principles in the Management of a Patient - ROJosonReynaldo Joson
This document outlines the application of management principles in managing a patient. It discusses establishing overall goals and strategies when a patient first consults, such as resolving their health issue without harm. It describes formulating a clinical diagnosis through interview and exam. The need for further testing is determined by diagnosis certainty and treatment plans. If needed, the most cost-effective test is selected. Finally, treatment options are considered based on benefit, risk, cost and availability to choose the most cost-effective option. The document provides examples of applying each step of the management process rationally.
Patient Compliance To Treatment In The Management Of Glaucoma And Factors Aff...Dr. Jagannath Boramani
This document discusses a study examining patient compliance with glaucoma treatment and factors affecting compliance. The study aims to prospectively analyze at least 100 glaucoma patients to assess compliance and its determinants. So far 15 patients have been enrolled, with poor overall compliance observed. Majority of noncompliant patients had low socioeconomic status and education. The study recommends various local and general measures to improve compliance, such as educational materials, family involvement, and assistance programs.
1) Patients leaving hospitals against medical advice (AMA) account for 1-2% of discharges annually in the US, totaling around 500,000 patients. These patients are often young, male, uninsured or on Medicaid, and treated at urban hospitals.
2) Contrary to common belief, insurance companies will often still reimburse hospitals for care provided to patients who leave AMA. A recent study found 100% of AMA patients from a Northshore emergency department were fully reimbursed.
3) Hospitals and doctors can take steps to reduce AMA discharges by educating staff, removing misleading forms, meeting with patients to address concerns, and arranging follow up care for patients who insist on leaving
Clinical decision making is the thinking processes & strategy we use to understand data with regard to identifying patient problems in preparation for diagnosis & selecting outcome & intervention
C H A P T E R 1
Clinical reasoning, evidencebased
practice, and symptom analysis
Basic health assessment involves the application of the practitioner’s knowledge and skills to identify and
distinguish normal from abnormal findings. Basic assessment often moves from a general survey of a body
system to specific observations or tests of function. Such an approach to assessment and clinical decision
making uses a deductive process of reasoning. For example, a specialist examining a patient with known
hyperthyroidism would conduct a physical examination to test for deep tendon reflexes. Brisk or hyperreflexic
reflexes would lead the practitioner to conclude that a hyperthyroid state is a likely cause of these findings. This
would greatly narrow the choices of diagnostic tests and treatment decisions.
Advanced assessment builds on basic health assessment yet is performed more often using an inductive or
inferential process, that is, moving from a specific physical finding or patient concern to a more general
diagnosis or possible diagnoses based on history, physical findings, and the results of laboratory and diagnostic
tests. The practitioner gathers further evidence and analyzes this evidence to arrive at a hypothesis that will lead
to a further narrowing of possibilities. This is known as the process of diagnostic reasoning.
Diagnostic reasoning
Diagnostic reasoning is a scientific process in which the practitioner suspects the cause of a patient’s symptoms
and signs based on previous knowledge. The practitioner gathers relevant information, selects necessary tests,
makes an accurate diagnosis, and recommends therapy. The difference between an average and an excellent
practitioner is the speed and focus used to arrive at the correct conclusion and initiate the best course of
evidencebased treatment with minimum harm, cost, inconvenience, and delay. This expertise of the
practitioner is acquired through knowledge and a skill set developed through experience in clinical practice.
Repeated practice with real cases helps to develop memory schemes for relating clinical problems and store
them in longterm memory.
By using diagnostic reasoning, the practitioner is able to accomplish the following:
• Determines and focuses on what needs to be asked, what data need to be obtained, and what needs to
be examined
• Performs examinations and diagnostic tests accurately
• Clusters all pertinent findings
• Analyzes and interprets the findings
• Develops a list of likely or differential diagnoses
The diagnostic process
The primary care context
The process of assessment in the primary care setting begins with the patient or caregiver stating a reason for
the visit or a chief concern. Most visits to primary care providers involve concerns or symptoms presented by
the patient, such as an earache, vomiting, or fatigue. The initial evidence is collected through a patient history.
Demographic information, such as gend ...
An expert discusses strategies for implementing a good academic emergency medicine training program. Key aspects include:
- Strong selection process and induction training to prepare students.
- Focused clinical rotations, electives, life support courses, procedures, and skills training to build proficiency.
- Daily teaching, case discussions, bedside learning and faculty coverage to mentor students.
- Evaluations, research, workshops and conferences to assess progress and support continued learning.
- Exit exams to ensure students have achieved expected competencies before completing the program.
This document discusses clinical audits in anaesthesia. It defines clinical audits as quality improvement processes that systematically review care against criteria to improve outcomes. The document outlines the history of audits dating back to Florence Nightingale. It describes different types of audits including clinical, critical event, outcome, training, and survey audits. The audit cycle is also explained as preparing criteria, measuring performance, implementing improvements, and sustaining changes. Barriers to audits are a lack of resources, expertise, and leadership. Audits aim to improve standards but challenges include support, time constraints, and obtaining consent.
- The POINT trial investigated whether clopidogrel plus aspirin reduces new ischemic vascular events compared to placebo plus aspirin in patients with minor stroke or high-risk TIA treated within 12 hours.
- Over 4,800 patients from 269 sites in 10 countries were randomly assigned to clopidogrel+aspirin or placebo+aspirin. Patients receiving clopidogrel had a 25% lower risk of stroke or other ischemic events but a higher risk of major bleeding.
- The trial was stopped early due to a safety signal of increased major hemorrhage in the clopidogrel group. However, clopidogrel was found to provide benefit for ischemic outcomes within the first 3 weeks
This document discusses observation units in emergency departments. It begins with introducing observation units and their objectives, then discusses the rationale and design features of such units. Key points covered include having clearly defined policies and staffing, focusing on conditions that can be better managed over a longer period of time than a traditional emergency department visit allows. The document also outlines potential pros and cons, as well as evidence from studies showing observation units can provide faster, better, cheaper care for certain patients.
The document discusses patient-centered outcomes for perioperative research. It proposes "disability-free survival" as a new outcome measure that is meaningful to patients. Disability-free survival combines survival rates with a validated patient-reported assessment of disability. The authors validate a short version of the World Health Organization Disability Assessment Schedule (WHODAS) for use in surgical patients. Widespread use of disability-free survival could improve shared decision making, quality metrics, and benchmarking by focusing on outcomes that matter to patients rather than surrogate outcomes or doctor perceptions of success.
Supratentorial intracerebral hemorrhage volume and other CT variables predict...NeurOptics, Inc.
However, it is not practical to obtain repeated serial CT scans in ICH patients to assess for these factors. A noninvasive indicator method of assessing the aforementioned factors would be very useful and could serve as a trigger for repeating a CT scan in a patient with ICH.
Decide treatment - a new approach to better healthØystein Eiring
Better treatment, better health! People often experience suboptimal health because treatment is not optimal. A new approach is being developed - enabling patients and doctors to improve treatment and improve health.
Contributing factors to patients overcrowding in emergency department at king...Alexander Decker
This document summarizes a study that explored factors contributing to patient overcrowding in the emergency department at King Saud Hospital in Unaizah, Saudi Arabia. The study found that the main factors were a lack of human resources, high population density, lack of beds, issues with public health awareness, and problems with emergency department design. A survey of 168 medical professionals at the hospital identified health awareness as having the highest impact and lack of beds as having the lowest impact on emergency department overcrowding. The study recommends strategies like increasing staffing levels and space in the emergency department.
Wijeysundera et al-2015-anesthesia_&_analgesiasamirsharshar
- The study found that patients managed by high-performing anesthesiologists experienced rates of postoperative death or major complications that were 45% lower than rates among patients managed by low-performing anesthesiologists.
- This confirms an implicit understanding among anesthesiologists that individual skill and performance varies, and that choice of anesthesiologist can impact patient outcomes, especially during complex high-risk procedures.
- Further research is needed to identify factors that explain variations in performance, such as procedure volume, and to leverage variations to identify best perioperative practices.
Virtual Reality Reflection Therapy Improves Balance and Gait in Patients with...Avi Dey
Technology enhanced version of Mirror Box Therapy called Virtual reality reflection therapy (VRRT) . Taesung In Et Al, (Department of Physical Therapy, College of Health Science, Sahmyook University, Seoul, South Korea) . Referred by Café Twin, Fairfax, VA USA. (LinkedIn.com/Café Twin) 2016
The document discusses trauma teams and their roles. It defines a trauma team as a multidisciplinary group that works together to assess and treat severely injured patients. A team approach has been shown to significantly reduce resuscitation times compared to individual doctors. The roles of trauma team members are outlined, as well as techniques for effective communication, briefing, handover, and speaking up if concerns arise. Statistics from Western Australia in 2015 show the most common causes of death for major trauma patients were head injuries and brain death. Overall mortality rates were lower than the national average.
The document discusses optimizing the use of atypical antipsychotics by reducing variability in patient care and outcomes. It outlines a four-step optimal care process: 1) making a proper diagnosis and communicating it to the patient, 2) considering acute symptom control and long-term goals in medication initiation, 3) adjusting treatment to achieve stability, and 4) maintaining care to minimize relapse. Barriers to optimal care are identified along with expert approaches to address them at each step of the care process.
Brain Health: The Importance of Recognizing Cognitive Impairment: An IAGG Con...Nutricia
This document summarizes the conclusions of an expert panel convened by the International Association of Gerontology and Geriatrics to discuss early detection of cognitive impairment. The panel agreed that:
1) Validated screening tests that take 3 to 7 minutes can identify early cognitive impairment.
2) The most effective approach is to use both patient-reported and informant-reported screening tools.
3) Early cognitive impairment may have treatable components, and emerging evidence supports interventions like medical treatment, nutrition changes, and physical/cognitive exercise to delay or reduce decline.
This document provides a practical protocol for using mirror therapy in stroke rehabilitation. It begins with an introduction to mirror therapy and its aims. Chapter I discusses general requirements for its use, including suitable patient characteristics, treatment aims, environment/materials needed, and treatment characteristics. Chapter II will describe the first therapy session in detail.
This document provides clinical care guidelines for the management of children presenting with symptoms or signs of acute encephalitis syndrome, with a focus on Japanese encephalitis. It was created by an international working group including experts from WHO, PATH, universities, and other organizations working on Japanese encephalitis. The guidelines are intended to guide the assessment and management of acutely ill children, especially those with fever, altered mental status, seizures, or other symptoms suggesting meningitis or encephalitis. They promote evidence-based and syndromic approaches to support rational and affordable therapy. The guidelines also discuss potential complications, medications, and include appendices with tools to aid assessment and management. Facilities should adapt the guidelines based on local illnesses,
Application of Management Principles in the Management of a Patient - ROJosonReynaldo Joson
This document outlines the application of management principles in managing a patient. It discusses establishing overall goals and strategies when a patient first consults, such as resolving their health issue without harm. It describes formulating a clinical diagnosis through interview and exam. The need for further testing is determined by diagnosis certainty and treatment plans. If needed, the most cost-effective test is selected. Finally, treatment options are considered based on benefit, risk, cost and availability to choose the most cost-effective option. The document provides examples of applying each step of the management process rationally.
Patient Compliance To Treatment In The Management Of Glaucoma And Factors Aff...Dr. Jagannath Boramani
This document discusses a study examining patient compliance with glaucoma treatment and factors affecting compliance. The study aims to prospectively analyze at least 100 glaucoma patients to assess compliance and its determinants. So far 15 patients have been enrolled, with poor overall compliance observed. Majority of noncompliant patients had low socioeconomic status and education. The study recommends various local and general measures to improve compliance, such as educational materials, family involvement, and assistance programs.
1) Patients leaving hospitals against medical advice (AMA) account for 1-2% of discharges annually in the US, totaling around 500,000 patients. These patients are often young, male, uninsured or on Medicaid, and treated at urban hospitals.
2) Contrary to common belief, insurance companies will often still reimburse hospitals for care provided to patients who leave AMA. A recent study found 100% of AMA patients from a Northshore emergency department were fully reimbursed.
3) Hospitals and doctors can take steps to reduce AMA discharges by educating staff, removing misleading forms, meeting with patients to address concerns, and arranging follow up care for patients who insist on leaving
Clinical decision making is the thinking processes & strategy we use to understand data with regard to identifying patient problems in preparation for diagnosis & selecting outcome & intervention
C H A P T E R 1
Clinical reasoning, evidencebased
practice, and symptom analysis
Basic health assessment involves the application of the practitioner’s knowledge and skills to identify and
distinguish normal from abnormal findings. Basic assessment often moves from a general survey of a body
system to specific observations or tests of function. Such an approach to assessment and clinical decision
making uses a deductive process of reasoning. For example, a specialist examining a patient with known
hyperthyroidism would conduct a physical examination to test for deep tendon reflexes. Brisk or hyperreflexic
reflexes would lead the practitioner to conclude that a hyperthyroid state is a likely cause of these findings. This
would greatly narrow the choices of diagnostic tests and treatment decisions.
Advanced assessment builds on basic health assessment yet is performed more often using an inductive or
inferential process, that is, moving from a specific physical finding or patient concern to a more general
diagnosis or possible diagnoses based on history, physical findings, and the results of laboratory and diagnostic
tests. The practitioner gathers further evidence and analyzes this evidence to arrive at a hypothesis that will lead
to a further narrowing of possibilities. This is known as the process of diagnostic reasoning.
Diagnostic reasoning
Diagnostic reasoning is a scientific process in which the practitioner suspects the cause of a patient’s symptoms
and signs based on previous knowledge. The practitioner gathers relevant information, selects necessary tests,
makes an accurate diagnosis, and recommends therapy. The difference between an average and an excellent
practitioner is the speed and focus used to arrive at the correct conclusion and initiate the best course of
evidencebased treatment with minimum harm, cost, inconvenience, and delay. This expertise of the
practitioner is acquired through knowledge and a skill set developed through experience in clinical practice.
Repeated practice with real cases helps to develop memory schemes for relating clinical problems and store
them in longterm memory.
By using diagnostic reasoning, the practitioner is able to accomplish the following:
• Determines and focuses on what needs to be asked, what data need to be obtained, and what needs to
be examined
• Performs examinations and diagnostic tests accurately
• Clusters all pertinent findings
• Analyzes and interprets the findings
• Develops a list of likely or differential diagnoses
The diagnostic process
The primary care context
The process of assessment in the primary care setting begins with the patient or caregiver stating a reason for
the visit or a chief concern. Most visits to primary care providers involve concerns or symptoms presented by
the patient, such as an earache, vomiting, or fatigue. The initial evidence is collected through a patient history.
Demographic information, such as gend ...
Evaluating medical literature guide final 5.7.12CreativeQi
This document provides a guide for medical students on evidence-based practice. It covers the basics of evidence-based practice, including that it involves integrating individual clinical expertise with the best available external evidence. It outlines the basic steps of asking an answerable clinical question using PICO, identifying the appropriate study type to answer the question, and understanding levels of evidence. The document provides guidance on searching the literature, including useful databases and search techniques. It also offers approaches for evaluating the literature from both a clinical and epidemiological perspective and communicating evidence to patients.
PERSONALIZED MEDICINE SUPPORT SYSTEM: RESOLVING CONFLICT IN ALLOCATION TO RIS...hiij
Treatment management in cancer patients is largely based on the use of a standardized set of predictive
and prognostic factors. The former are used to evaluate specific clinical interventions, and they can be
useful for selecting treatments because they directly predict the response to a treatment. The latter are used
to evaluate a patient’s overall outcomes, and can be used to identify the risks or recurrence of a disease.
Current intelligent systems can be a solution for transferring advancements in molecular biology into
practice, especially for predicting the molecular response to molecular targeted therapy and the prognosis
of risk groups in cancer medicine. This framework primarily focuses on the importance of integrating
domain knowledge in predictive and prognostic models for personalized treatment. Our personalized
medicine support system provides the needed support in complex decisions and can be incorporated into a
treatment guide for selecting molecular targeted therapies.
PERSONALIZED MEDICINE SUPPORT SYSTEM: RESOLVING CONFLICT IN ALLOCATION TO RIS...hiij
Treatment management in cancer patients is largely based on the use of a standardized set of predictive
and prognostic factors. The former are used to evaluate specific clinical interventions, and they can be
useful for selecting treatments because they directly predict the response to a treatment. The latter are used
to evaluate a patient’s overall outcomes, and can be used to identify the risks or recurrence of a disease.
Current intelligent systems can be a solution for transferring advancements in molecular biology into
practice, especially for predicting the molecular response to molecular targeted therapy and the prognosis
of risk groups in cancer medicine. This framework primarily focuses on the importance of integrating
domain knowledge in predictive and prognostic models for personalized treatment. Our personalized
medicine support system provides the needed support in complex decisions and can be incorporated into a
treatment guide for selecting molecular targeted therapies.
PERSONALIZED MEDICINE SUPPORT SYSTEM: RESOLVING CONFLICT IN ALLOCATION TO RI...hiij
Treatment management in cancer patients is largely based on the use of a standardized set of predictive and prognostic factors. The former are used to evaluate specific clinical interventions, and they can be useful for selecting treatments because they directly predict the response to a treatment. The latter are used to evaluate a patient’s overall outcomes, and can be used to identify the risks or recurrence of a disease. Current intelligent systems can be a solution for transferring advancements in molecular biology into practice, especially for predicting the molecular response to molecular targeted therapy and the prognosis of risk groups in cancer medicine. This framework primarily focuses on the importance of integrating domain knowledge in predictive and prognostic models for personalized treatment. Our personalized medicine support system provides the needed support in complex decisions and can be incorporated into a treatment guide for selecting molecular targeted therapies.
PERSONALIZED MEDICINE SUPPORT SYSTEM: RESOLVING CONFLICT IN ALLOCATION TO RIS...hiij
This document discusses developing a personalized medicine support system that can predict patient molecular response to targeted cancer therapies and assess patient risk groups. It reviews using clinical data and knowledge from sources like clinical trials and electronic health records to build predictive and prognostic models. Key challenges include resolving conflicts between different data sources and knowledge, and distinguishing predictive factors that predict treatment response from prognostic factors that predict overall patient outcomes. The system aims to integrate domain knowledge and provide decision support for personalized cancer treatment.
MULTI-CRITERIA DECISION SUPPORT GUIDED BY CASE-BASED REASONINGcsandit
Many systems based on knowledge, especially expert systems for medical decision support have
been developed. Only systems are based on production rules, and cannot learn and evolve only
by updating them. In addition, taking into account several criteria induces an exorbitant number
of rules to be injected into the system. It becomes difficult to translate medical knowledge or a
support decision as a simple rule. Moreover, reasoning based on generic cases became classic
and can even reduce the range of possible solutions. To remedy that, we propose an approach
based on using a multi-criteria decision guided by a case-based reasoning (CBR) approach.
Population Management PCMH 2011 - Northwest Medical Partnerspedenton
This document provides information on population management in healthcare, including:
1) It introduces concepts of preventive medicine and outlines why population management and preventive care management are important.
2) It discusses strategies for managing patient populations, such as identifying groups due for certain screenings and reaching out to schedule them.
3) The document also reviews guidelines and recommendations from organizations like the US Preventive Services Task Force for various cancer screenings and preventive services.
18Falls in The Long-Term Care SettingsNayaris ReyeAnastaciaShadelb
1
8
Falls in The Long-Term Care Settings
Nayaris Reyes
Florida National University
June 12, 2021
Brief Literature Review
The elderly in the long-term care facilities are typically predisposed to falling and might fall for various reasons. Some predisposing factors might be related to unsteady balance and gait, poor vision, weak muscles, dementia, and medications. In addition, various medical conditions, including stroke, low blood pressure, brain disorders, and poorly managed epilepsy, might increase older people's risk for falls (Golmakani et al., 2014). Therefore, several studies have been conducted to evaluate the efficacy of multi-factorial interventions on the occurrence of falls in long-term care settings, including psycho-geriatric nursing home patients. Based on the clinical study, it was concluded that various multi-factorial interventions used in preventing falls such as a general medical assessment emphasizing falls, specific fall risk evaluation devices, assessing medication intake, fall history, and mobility, using protective and assistive aids play a significant role in reducing the incidence of falls among the elderly (Ungar et al., 2013). Accordingly, it was evident that fall prevention, usually geared towards psycho-geriatric patients in a long-term care facility, is possible and efficient in minimizing falls among older people.
Other researchers carried out a study in developing a fall prevention program for the aged patients in long-term care entities, especially those at risk of falling, by increasing caregiving expertise or skills and motivating staff members. From the analysis, exercise programs encompassing warm-up, muscle reinforcement, especially in the lower extremities, and proprioceptive neuromuscular expedition are used in increasing motivation and caregiving skills (Donath et al., 2016). Another research conducted to evaluate the statistics of falls among the elderly found out that falls are the leading cause of injury-interrelated visits to emergency facilities in the U.S. They are also the primary etiology of accidental deaths in persons aged 60 and above. From the analysis, falls might be markers of diminishing function and poor health and are significantly attributable to morbidity.
To assess the risk factors related with falls among the older people in the long-term care facilities, it was realized that more than 25% of facility-dwelling older individuals and 60% of nursing home residents fall yearly (Pfortmueller et al., 2014). Various risk factors linked to their falls are medication use, increasing age, sensory deficits, and cognitive impairment. Studies depict that older persons who have fallen must undergo a thorough clinical evaluation (within the facilities) to analyze the preventive strategies further. This will aid in determining and treating the underlying cause of their falls, return them to baseline function, and minimize the likelihood of recurrent falls (Karlsson et al., 20 ...
This document provides an overview of the nursing process. It begins by outlining the objectives of understanding the nursing process, its characteristics, benefits, and phases. It then defines the nursing process as a modified scientific method used to assess client needs and develop a care plan. The key phases are described as assessment, nursing diagnosis, planning, implementation, and evaluation. Assessment involves collecting client data, nursing diagnosis identifies responses to health issues, planning develops the care approach, implementation provides care, and evaluation assesses effectiveness. The document explains each phase in further detail.
This document discusses nursing diagnosis, including its definition, steps for formulating a nursing diagnosis, categories and types. It defines nursing diagnosis as a statement of a health problem or potential problem that a nurse can treat. The steps for formulation include establishing a database through various assessments, analyzing client responses, organizing the data, and confirming the diagnosis. Nursing diagnoses can be actual, risk, or potential complications. They should not merely restate a medical diagnosis but provide a basis for nursing interventions.
RESEARCH ARTICLE Open AccessDelivering an evidence-based o.docxrgladys1
RESEARCH ARTICLE Open Access
Delivering an evidence-based outdoor journey
intervention to people with stroke: Barriers and
enablers experienced by community
rehabilitation teams
Annie McCluskey1*†, Sandy Middleton2,3*†
Abstract
Background: Transferring knowledge from research into practice can be challenging, partly because the process
involves a change in attitudes, roles and behaviour by individuals and teams. Helping teams to identify then target
potential barriers may aid the knowledge transfer process. The aim of this study was to identify barriers and
enablers, as perceived by allied health professionals, to delivering an evidence-based (Level 1) outdoor journey
intervention for people with stroke.
Methods: A qualitative design and semi-structured interviews were used. Allied health professionals (n = 13) from two
community rehabilitation teams were interviewed, before and after receiving feedback from a medical record audit and
attending a training workshop. Interviews allowed participants to identify potential and actual barriers, as well as enablers to
delivering the intervention. Qualitative data were analysed using theoretical domains described by Michie and colleagues.
Results: Two barriers to delivery of the intervention were the social influence of people with stroke and their
family, and professionals’ beliefs about their capabilities. Other barriers included professionals’ knowledge and skills,
their role identity, availability of resources, whether professionals remembered to provide the intervention, and
how they felt about delivering the intervention. Enablers to delivering the intervention included a belief that they
could deliver the intervention, a willingness to expand and share professional roles, procedures that reminded
them what to do, and feeling good about helping people with stroke to participate.
Conclusions: This study represents one step in the quality improvement process. The interviews encouraged
reflection by staff. We obtained valuable data which have been used to plan behaviour change interventions
addressing identified barriers. Our methods may assist other researchers who need to design similar behaviour
change interventions.
Background
Translating Evidence into Practice
Translating evidence into practice, or implementation is
an active process involving individuals, teams and orga-
nisations [1]. Knowledge translation is an important
final step in the process of evidence-based practice. This
step is challenging and involves changes in attitude and
behaviour. Researchers cannot assume that an interven-
tion which demonstrates a positive effect and has been
described in a high impact journal will be translated in
practice [2]. Nor should researchers assume that the
majority of people with a health condition will receive
that intervention [3].
Barrier identification is an important first step in the
process of knowledge translation [4]. Failure to anticipate
problems and barriers may lead to disa.
Delirium Care Pathway MoDelirium Care Pathway Model Design: STOP DELIRIUMdel ...komalicarol
We present a delirium care pathway model that we have dubbed
STOP DELIRIUM. Due to delirium's magnitude and effect in elderly hospitalized patients, we recommend hospitals must have
a delirium care pathway for early identification, prevention, and
delirium management. The protocol STOP DELIRIUM is driven
from evidence-based guidelines to help establish the aim "STOP"
for Spot, Think, Optimize and Prevent delirium. The clinical
pathway model needs to incorporate a clinical information management system and educational materials to increase delirium
awareness. The implementation should be scalable and adaptable
to incorporate other departments.
Description This is a continuation of the health promotion pro.docxmecklenburgstrelitzh
Description
This is a continuation of the health promotion program proposal, part one, which you submitted previously. Please approach this assignment as an opportunity to integrate instructor feedback from part I and expand on ideas adhering to the components of the MAP-IT strategy. Include necessary levels of detail you feel appropriate to assure stakeholder buy-in.
Directions
For this assignment add criteria 5-8 as detailed below:
5. Propose a health promotion program using an evidence-based intervention found in your literature search to address the problem in the selected population/setting. Include a thorough discussion of the specifics of this intervention which include resources necessary, those involved, and feasibility for a nurse in an advanced role. Be certain to include a timeline. ( 3 paragraph. You may use bullets if appropriate).
6. Thoroughly describe the intended outcomes. Describe the outcomes in detail concurrent with the SMART goal approach. (1 paragraph).
7. Provide a detailed plan for evaluation for each outcome. (1 paragraph).
8. Thoroughly describe possible barriers/challenges to implementing the proposed project as well as strategies to address these barriers/challenges. (1 paragraph).
9. Conclude the paper with a Conclusion paragraph. Don’t type the word “Conclusion”. Here you will share your insights about this strategy and your expectations regarding achieving your goals. (1 paragraph).
Paper Requirements
Your assignment should be 3 pages (excluding title page, references, and appendices), following APA standards.
Remember, your Proposal must be a scholarly paper demonstrating graduate school level writing and critical analysis of existing nursing knowledge about health promotion.
Please add this section to the PART 1 ATTACHED , must be one document for the entire work, AGAIN this 4 pages you will do now, please add it to the PART 1 ATTACHED, add references for this section and put them properly in APA style with the previously in the PART 1.
[removed]
Running head: CONGESTIVE HEART FAILURE Page 2
Patients with Congestive Heart failure and Increased Readmission Rates
Florida National University
NGR 6638
Professor Alexander Garcia Salas DNP, MSN, ARNP, FNP-C
Congestive heart failure (CHF), which affects millions of people, especially the elderly, is a significant and expanding public health concern. According to research, CHF accounts for between 12 and 15 million office visits and 6.5 million inpatient days annually (Hollier, 2021). Unfortunately, this approach leads to disease progression and rehospitalizations for many CHF patients because of insufficient care, unclear discharge instructions, and a lack of follow-up visits. These higher rehospitalization rates are driving up expenses and indicating that existing care strategies for CHF are not the most effective. Therefore, evidence-based t.
Comparisonof Clinical Diagnoses versus Computerized Test Diagnoses Using the ...Nelson Hendler
The Diagnostic Paradigm from www.MarylandClinicalDiagnostics.com was able to help the former Dean of Los Angeles Chiropractic College detect medical diagnoses which he had overlooked, and he later confirmed.
REVIEWWhat are the benefits of medical screeningand surv.docxmalbert5
REVIEW
What are the benefits of medical screening
and surveillance?
Dennis Wilken*, Xaver Baur*, Lioubov Barbinova*, Alexandra Preisser*,
Evert Meijer#, Jos Rooyackers" and Dick Heederik# on behalf of the ERS Task Force
on the Management of Work-related Asthma+
ABSTRACT: Pre-employment examination is considered to be an important practice and is
commonly performed in several countries within the European Union. The benefits of medical
surveillance programmes are not generally accepted and their structure is often inconsistent.
The aim of this review was to evaluate, on the basis of the available literature, the usefulness of
medical screening and surveillance. MEDLINE was searched from its inception up to March 2010.
Retrieved literature was evaluated in a peer-review process and relevant data was collected
following a systematic extraction schema.
Pre-placement screening identifies subjects who are at an increased risk for developing work-
related allergic disease, but pre-employment screening is too low to be used as exclusion criteria.
Medical surveillance programmes can identify workers who have, or who are developing, work-
related asthma. These programmes can also be used to avoid worsening of symptoms by
implementing preventive measures. A combination of different tools within the surveillance
programme, adjusted for the risk of the individual worker, improves the predictive value.
Medical surveillance programmes provide medical as well as socioeconomic benefits.
However, pre-employment screening cannot be used to exclude workers. They may act as a
starting point for surveillance strategies. A stratified approach can increase the effectiveness and
reduce the costs for such programmes.
KEYWORDS: Nonspecific bronchial hyperresponsiveness, pre-employment examination,
sensitisation, skin-prick test, work-related asthma
D
ue to heterogenous usage of the terms
‘‘medical screening’’ and ‘‘medical sur-
veillance’’, we will first describe these
terms as they are referred to in this article.
Medical screening, in the strictest sense, is a
method for detecting disease or body dysfunc-
tion before an individual would normally seek
medical care. The fundamental purpose of
screening is early diagnosis and treatment of
the individual and, thus, it has a clinical focus.
Screening tests are usually administered to
individuals in a larger population who have
not yet sought medical care, but who may be at
high risk for certain adverse health outcomes. In
essence, it involves detection of individuals with
an elevated probability of having the disorder
in question. In the occupational asthma field,
the term ‘‘screening’’ is often used more loosely
for detecting individuals with existing disease
(secondary or tertiary prevention) to avoid
worsening. Related to screening is the activity
of screening not for the presence of disease, but
for the presence of risk factors of disease. This
activity has been suggested for use in pre-
employment or pre-pl.
Therapeutic exercise is intended to remediate or prevent impairments, improve physical function, and optimize health through planned movements, postures, and physical activities. It involves 10 components including aerobic conditioning, muscle performance exercises, stretching, joint mobilization, neuromuscular control techniques, and more. Safety is fundamental, with factors like health history, environment, and accuracy of performance influencing risk. Clinical decision making in selecting and modifying exercises requires reasoning skills and evidence-based practice. The process of patient management has five components: examination, evaluation, diagnosis, prognosis/care plan based on goals, and implementing interventions.
Similar to Schemes for medical decision making a primer for trainees (20)
Covid-19 Clinical Case: Lessons & Recommendations-updated Jan 2021Imad Hassan
This document describes the case of a 65-year-old male patient with diabetes, dyslipidemia, and vitamin D deficiency who was hospitalized for COVID-19 pneumonia. Over the course of his 16-day hospitalization, he received various treatments including antibiotics, steroids, anticoagulants, and supplements. His inflammatory markers initially increased but then decreased with treatment. He developed a pulmonary embolism but ultimately improved and was discharged. The document emphasizes using COVID-19 scoring tools to assess risk and employing current best practices for treatment.
I understand this is difficult to discuss. Let's take a step back - my role is not to judge but to understand your perspective and support you in making choices that align with your values and priorities. Perhaps we could explore how drinking fits into your life goals and what matters most to you.
Write the first draft of your scientific paper in less than 1 day!Imad Hassan
This document provides tips for writing the first draft of a paper in less than one day. It recommends deciding on the topic and type of article, writing a title and keywords, searching databases to find relevant papers and learn structure, copying abstracts and references, choosing journals, checking author guidelines, using their headings to structure the draft, and proofreading before submitting. The key steps are researching the topic thoroughly, learning from other papers, and using author guidelines to write a structured first draft within a day.
Introduction to Competency-based Medical EducationImad Hassan
This document discusses competency-based medical education (CBME) and key related concepts. It provides an overview of CBME, defining it as an outcomes-based approach using a framework of competencies. Key terms are defined, including competence, competency, and competent. The importance of entrustable professional activities (EPAs) and milestones in assessing competencies is described. The relationship between competencies, EPAs, and milestones is explained. An example case scenario is provided to illustrate how these concepts integrate in clinical practice.
Competency-based Medical Education CurriculumImad Hassan
This document outlines plans to restructure medical training at an institution to a competency-based model. It discusses transforming the curriculum, faculty development, assessment tools, and training processes. The plans include establishing competency-focused committees and faculty/resident teams. Training workshops will develop materials for each CanMEDS competency. Assessment tools like online logbooks and end-of-rotation evaluations will evaluate competencies. Educational activities like ward rounds and morning meetings will highlight competencies. The overall goal is to implement a competency-based medical education approach to improve training outcomes.
Introduces Value-based Healthcare, an important concept for transforming healthcare making it more cost-effective, sustainable, and patient-centered. Strategically, it makes the healthcare providers accountable to the desired patient and health system "valued" outcomes.
https://youtu.be/-oOuJfpRFpY
Strategies to fix healthcare systems v1Imad Hassan
3. Names the essential and strategic concepts that leaders in healthcare need to master. They need to be incorporated into any modern healthcare system to make it successful, sustainable and highly-responsive. Around 6 minutes.
https://youtu.be/KQRxbNORHF8
Breaking Bad News https://www.youtube.com/watch?v=AK1r-1gJkSkImad Hassan
This document provides information and guidance on effectively breaking bad news to patients. It discusses why mastering this skill is important, as effective communication can improve patient outcomes. It defines bad news as any information that drastically changes a patient's view of their future. The document recommends using empathy and active listening skills when delivering bad news. It presents the SPIKES protocol as a framework, including setting, perception, invitation, knowledge, emotions, and strategy/summary. Examples of conditions requiring bad news and techniques like the "sandwich method" are provided. The overall message is the importance of compassion and ensuring patients understand their diagnosis and future options.
This document discusses strategies for reducing hospital readmissions of patients with chronic heart failure. It provides background on the high rates of readmission and costs associated with heart failure. It then examines various interventions that have been shown to reduce readmissions through systematic reviews and meta-analyses. These include multicomponent quality improvement programs involving education, specialized clinics, telemedicine, medications, and cardiac rehabilitation. Adherence to guideline-directed medical therapies and addressing comorbidities are also emphasized.
Diagnosing heart failure in patients with & without copd Imad Hassan
This document provides information on diagnosing heart failure in patients presenting with dyspnea. It discusses the case of a 54-year-old male patient and lists examination findings suggestive of heart failure. Tests that may help differentiate causes of dyspnea are outlined, including BNP levels, chest X-ray, echocardiogram, and lung ultrasound. Scores on the heart failure prediction rule and elevated mean platelet volume further support a diagnosis of heart failure over COPD in some patients. Clinical findings, biomarker results, and imaging must all be considered to accurately diagnose heart failure as the cause of dyspnea.
This document provides an overview of an evidence-based medicine primer training series. It begins with an introduction that emphasizes the importance of evidence-based practice and moving ahead of colleagues.
The presentation plan outlines the topics to be covered, including the need for EBP, the concept and definition of EBP, the steps and tools involved in practicing EBM, and how to self-educate in EBM.
Subsequent sections provide more details on key aspects of EBP such as asking clinical questions, acquiring the best evidence, appraising evidence, and applying evidence to patients. Numbers and metrics used in EBM are discussed like NNT, LR, and applicability of evidence to practice. Resources for learning EBM
Strategies to initiate & promote research v1Imad Hassan
This document discusses how to initiate and promote research in health institutions. It begins by defining research and outlining its key characteristics and importance. Specifically, research generates new knowledge and technologies to address health problems, and identifies priority issues to design and evaluate policies and programs. Two prerequisites for research are structures and processes. Key structures include offices, equipment, personnel like researchers and statisticians, and funding. Processes to stimulate research activities involve developing research faculties through training, protecting research time, holding research days and journal clubs, and linking recruitment/promotion to research output. The document also provides ideas to enhance research output, such as providing incentives for publications, holding weekly research meetings, enabling inter-departmental and multi-center collaboration, and
The mind of a master clinician pillars of excellence - ss1Imad Hassan
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Strategies to initiate & promote research ss1Imad Hassan
This document provides guidance on initiating and promoting research in health institutions. It discusses the importance of research and outlines key prerequisites including necessary structures and processes. Structures that are essential for initiating research include offices, equipment, research committees, personnel like researchers and statisticians, and funding. Key processes include developing research faculties through regular training, protecting research time, recruitment linked to research track records, and incentive programs. Mechanisms to enhance output include weekly research meetings, inter-departmental collaboration, multi-center research, research rotations, and maintaining a "research ideas" bank linked to institutional needs. The overall document serves as a guide for setting up effective research programs and stimulating research activities in health organizations.
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The document discusses the differences between old and new models of healthcare systems and processes. The old model was organized by medical specialty in silos, with single consultant-led teams and decision making left to individuals. The new model emphasizes integrated multi-disciplinary teams organized by disease, standardized evidence-based care, system-wide safety practices, electronic records, continuous quality measurement, and patient-centered holistic care. The new model aims to anticipate needs, engage all stakeholders, and prioritize waste reduction and transparency over cost reduction.
The document outlines 7 steps for successful service improvement:
1. Leadership declares adoption of new practices and all employees are change agents.
2. Leadership creates a sense of urgency with a clear vision of goals.
3. Change teams are created with expert leaders to lead knowledge translation.
4. Areas needing change are identified and prioritized through a needs assessment.
5. Barriers to improvement like training or motivation are assessed.
6. Competent trainers are created to train staff on new interventions.
7. Monitoring teams with reward systems are created to ensure compliance.
Mastering clinical communication v2 ss1Imad Hassan
This document provides guidance on mastering patient communication skills for healthcare providers. It discusses the importance of the patient-doctor relationship for improved outcomes. It outlines key principles for effective communication, including showing empathy, giving hope, mastering non-verbal cues, and using therapeutic communication. Specific best practices are described, such as active listening, sharing observations, and motivating patients. The document also identifies negative communication behaviors to avoid, like focusing only on bad news, asking irrelevant personal questions, and arguing with patients. The overall message is that developing strong interpersonal skills is essential for building trust with patients and enhancing their health and well-being.
1. The document discusses the history and objectives of journal clubs, which began in the 1800s as a way for physicians to critically discuss recent medical literature.
2. Journal clubs aim to improve knowledge and skills in evidence-based medicine, communication, and quality improvement by changing practices based on evidence.
3. Studies have found that journal clubs may be effective in improving reading habits, knowledge of epidemiology and biostatistics, and use of medical literature, though their impact on critical appraisal skills requires more research.
Are you looking for a long-lasting solution to your missing tooth?
Dental implants are the most common type of method for replacing the missing tooth. Unlike dentures or bridges, implants are surgically placed in the jawbone. In layman’s terms, a dental implant is similar to the natural root of the tooth. It offers a stable foundation for the artificial tooth giving it the look, feel, and function similar to the natural tooth.
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdfrightmanforbloodline
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdf
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdf
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Kosmoderma Academy, a leading institution in the field of dermatology and aesthetics, offers comprehensive courses in cosmetology and trichology. Our specialized courses on PRP (Hair), DR+Growth Factor, GFC, and Qr678 are designed to equip practitioners with advanced skills and knowledge to excel in hair restoration and growth treatments.
These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
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Birth period, socioeconomical status, nutritional and intrauterine environment are the factors influencing low birth weight
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It is mostly found in the brain, intestines, and blood platelets.
5-HT is utilised to transport messages between nerve cells, is known to be involved in smooth muscle contraction, and adds to overall well-being and pleasure, among other benefits. 5-HT regulates the body's sleep-wake cycles and internal clock by acting as a precursor to melatonin.
It is hypothesised to regulate hunger, emotions, motor, cognitive, and autonomic processes.
The skin is the largest organ and its health plays a vital role among the other sense organs. The skin concerns like acne breakout, psoriasis, or anything similar along the lines, finding a qualified and experienced dermatologist becomes paramount.
Travel Clinic Cardiff: Health Advice for International TravelersNX Healthcare
Travel Clinic Cardiff offers comprehensive travel health services, including vaccinations, travel advice, and preventive care for international travelers. Our expert team ensures you are well-prepared and protected for your journey, providing personalized consultations tailored to your destination. Conveniently located in Cardiff, we help you travel with confidence and peace of mind. Visit us: www.nxhealthcare.co.uk
Schemes for medical decision making a primer for trainees
1. Cognitive schemes and strategies in
diagnostic and therapeutic decision
making: a primer for trainees
Imad Salah Ahmed Hassan
Perspectives on Medical Education
ISSN 2212-2761
Volume 2
Combined 5-6
Perspect Med Educ (2013) 2:321-331
DOI 10.1007/s40037-013-0070-3
1 23
2. Your article is published under the Creative
Commons Attribution license which allows
users to read, copy, distribute and make
derivative works, as long as the author of
the original work is cited. You may selfarchive this article on your own website, an
institutional repository or funder’s repository
and make it publicly available immediately.
1 23
3. Perspect Med Educ (2013) 2:321–331
DOI 10.1007/s40037-013-0070-3
REVIEW ARTICLE
Cognitive schemes and strategies in diagnostic
and therapeutic decision making: a primer for trainees
Imad Salah Ahmed Hassan
Published online: 11 July 2013
Ó The Author(s) 2013. This article is published with open access at Springerlink.com
Abstract
Unlike novices, expert clinicians develop refined schemes and strategies that
predictably allow them to provide a better quality, prompt and less error-prone
patient care input. Empowering novices with cognitive aids or mental schemes as
early as possible in their clinical career may significantly improve their critical
thinking, problem-solving and decision-making skills. These cognitive aids may also
improve trainees’ use of evidence-based medicine in addition to reducing their
diagnostic errors and improving their therapeutic care inputs.
Keywords
Schemes Á Decision-making Á Novices Á Experts
Introduction
Optimal problem-solving, clinical reasoning and rational decision-making are
indispensable skills for quality care provision. These coupled with a comprehensive
knowledge base are the two components of an ‘expert medical practitioner’.
Cognitive conceptual deficiencies in decision-making have been shown to be an
important cause of diagnostic errors, deficient therapeutic interventions and poor
outcomes in both acute and ambulatory care settings [1–5]. Unlike novices, clinical
experts tend to utilize ‘mental schemes’ for problem-solving, clinical reasoning and
rational decision-making [6]. Research has confirmed that equipping trainees with
the experts distinguishing, scheme-driven strategies significantly improves their
decision-making skills, specifically in the diagnosis domain [7]. In essence, these
schemes are knowledge and experience-based, cognitive aids that facilitate
I. S. A. Hassan (&)
Department of Medicine 1443, King Saud bin Abdulaziz University for Health Sciences and King
Abdulaziz Medical City, P. O. Box 22490, Riyadh 11426, Saudi Arabia
email: imadsahassan@yahoo.co.uk
123
4. 322
I. S. A. Hassan
Table 1 Actions map for a patient encounter and their cognitive schemes
Step
Clinical action
Scheme/cognitive aid
1
Gather information (history and
physical)
–
2
Propose a diagnosis
Pattern-recognition hypothetico-deductive strategies and smart
heuristics, rule-out worst scenario, red flags, etc.
3
Differential diagnosis
Differential diagnosis cognitive aids: anatomical, physiological,
pathological
4
Order tests (rationally)
Frugal heuristics probability assessment: test sensitivity,
specificity and likelihood ratios
5
Confirm and comprehensively
give a diagnostic label
Guideline-friendly bedside diagnosis, aetiology, severity
(BESD)
6
Therapeutic interventions
Contextual, patient-centred therapeutic cognitive aid: site of
care, symptomatic, supportive, specific and speciality referral
(5S)
7
Prepare for discharge
Assess response to treatment (subjective and objective), criteria
for discharge, timing of follow-up (ACT)
knowledge retrieval from the expert’s memory, thereby enhancing the practical
instigation of a logical and organized problem-solving approach. It is anticipated that
scheme-based cognitive training of novices and juniors will enhance their diagnostic
problem-solving and decision-making abilities at an earlier stage in their career [6].
Generic cognitive aids or schemes presented in easy to recall, structured concept
maps may thus serve as simple reminders to front-line staff, especially novices, on
how to approach diagnostic and therapeutic uncertainties peculiar to their patients. It
is generally believed that clinicians utilize two modes of reasoning for decisionmaking, namely System 1 and System 2 [8–10]. System 1 is a non-analytic, fast and
intuitive one usually based on previous exposure whilst System 2 is an analytic, slow
and rational mode acquired through structured training. Both are generally used
interchangeably, yet System 1 is more error-prone. Cognitive aids used as ‘cognitive
forcing strategies’ [11] should in principle facilitate and promote the use of System 2
in critical thinking and decision-making.
In this monograph, an approach for diagnostic and therapeutic decision-making
using cognitive aids or schemes is presented. Cognitive aids, schemes and concept
maps are used interchangeably. Hypothetical case scenarios are portrayed to assist in
a better understanding of the concepts depicted in the monograph. Table 1 portrays
the various steps or actions map in a patient encounter and its recommended
cognitive schemes.
Step 1: building knowledge and summarizing the problem
The first step in any clinical encounter is ‘information gathering’. This is achieved
through history taking and physical examination. A skilled yet brief visual and
auditory assessment of the patient allows the relatively experienced clinician to
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5. Schemes for decision making
Box 1
323
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
decide on the severity and seriousness of the presenting symptom. Once a complete
and focused history and physical examination are completed, a vital step and an
essential prerequisite before proceeding any further is to skilfully articulate a short
summary of the clinical history and examination findings emphasizing only the
positive and relevant features. The latter should additionally be phrased in conclusive
technical medical terms, e.g. symptoms of lateral chest pain with coughing are
qualified as pleuritic, red urine as haematuria, non-swollen, painful joints as
arthralgia, stony dullness on examination as pleural effusion, enlarged spleen as
splenomegaly, a single, swollen, painful joint as mono-arthritis, etc. Mastering this
skill differentiates the novice from the expert and is generally conducive to better
decision-making [12]. A structured, summary template for generic use is shown in
Box 1.
Step 2: making the diagnosis
The next step is making a bedside clinical diagnosis or a short list of a few
differential diagnoses. This is probably the most crucial step in a patient encounter
and the most error-prone [1, 2, 4]. Cognitive as well system errors contribute to
patient harm and poorer outcomes [1, 2, 4]. As such, cognitive, individual or
caregiver aids and strategies (as well as system interventions, see below) to enhance
the trainees’ diagnostic accuracy and therapeutic interventions are indispensable
[13, 14].
A four-phased scheme is depicted:
Reaching a bedside clinical diagnosis using pattern recognition
and hypothetico-deductive strategies [15]
Pattern recognition is the simplest and non-analytic ‘spot diagnosis’ of a clinical
presentation usually based on classic visual clues or specific test finding. For
example, the rash of herpes zoster, the facies of a patient with acromegaly and the
electrocardiogram findings of an acute myocardial infarction. Another patternrecognition strategy is achieved through heuristics [16, 17]. Heuristics are mostly
history-based, expert-employed, pattern-recognizing ‘rules of thumb’ or short-cut
decision strategies that rely on a small fraction of the gathered information (relevant
or trustworthy predictors) for considering a diagnosis. For example, a middle-aged
smoker with central chest pain radiating to his left upper limb will automatically be
labelled as having an acute coronary syndrome. Similarly, a postoperative patient
with a single swollen leg, shortness of breath and haemoptysis will be labelled as
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suffering from pulmonary thromboembolism and a 12-year-old with a right-iliac
fossa pain that started para-umbilically and is associated with anorexia and vomiting
will be given the diagnosis of acute appendicitis. Although both visual and historybased pattern recognition strategies are fast decision/diagnostic strategies, heuristic,
pattern recognition is of lower fidelity and reliability than visual, pattern recognition
spot diagnosis and is thus more error-prone [16, 17].
However, many clinical encounters and diagnostic challenges are primarily
unravelled using another strategy: the hypothetico-deductive strategy [15].
Clinicians utilize clinical and epidemiological clues from the information gathered
by history-taking and possibly substantiated by physical examination to arrive at a
single diagnosis or a short-list of differential diagnosis. As mentioned above, this is a
critical and error-prone stage for novices [1, 4]. Skilled experts revert to at least two
other strategies to solve the diagnostic puzzle whilst excluding immediate lifethreatening or ‘not-to-miss’ diagnoses: ‘red flags’ and ‘rule out the worst scenario’
(ROWS) [18].
ROWS and red flags are strategies that assist the clinician to avoid missing the
most serious of the possible differential diagnoses. For example, the expert will
automatically enquire, examine and investigate for the more serious causes of central
chest pain such as acute coronary syndrome and aortic dissection rather than for the
other less serious causes such as oesophageal spasm. Similarly, meningitis and
intracranial vascular events will be the primary concerns for the expert interviewing a
patient with headache. Red flags for the latter scenario (acute meningitis) may
include symptoms such as fever and photophobia and signs such as neck stiffness and
change in sensorium. Checklists of red flags may be utilized by the novice to
safeguard against missing serious problems.
A simple heuristic that helps to narrow the differential diagnosis is trying to
categorize the disease as secondary to one organ/system involvement or multisystemic. A patient with fever and primarily respiratory-associated symptomatology
points to a respiratory system pathology while the presence of symptoms related to
several organ systems point to a multi-system disease.
Constructing a differential diagnosis
An important and well-recognized cause of diagnostic errors is failing to consider
alternative diagnoses [3, 5]. This is inherent to fully relying on heuristics for reaching
a clinical diagnosis [16, 17]. Heuristics as such are obviously error-prone. Trainees
must be equipped with simple concept maps or cognitive aids to seamlessly construct
a list of possible differential diagnoses [7]. These ‘schemes’ guide the trainee in
constructing a hypothesis-driven [19, 20], focused, rational, history taking,
examination and investigation plan. Three cognitive aids are depicted in Table 2.
The differential diagnosis of pain and swellings is generally anatomical.
Physiological differential diagnosis listing is especially applicable to two medical
problems, namely shock and thrombosis. All differential diagnosis listings may,
however, be easily structured along the two pathological or aetiopathological entities
of: congenital/hereditary or acquired. The latter may be sub-classified into 10
categories: traumatic, infective, inflammatory/autoimmune, vascular/degenerative,
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7. Schemes for decision making
Table 2
325
Differential diagnosis cognitive aids
Anatomical differential
diagnosis
Physiological differential
diagnosis
Aetiopathological differential
diagnosis
Pain syndromes e.g. central
chest pain may be
categorized as arising from
the heart, aorta, oesophagus,
chest wall etc.
Shock this may be hypovolaemic,
distributive, obstructive or
cardiogenic
Congenital or hereditary
Swellings e.g. a neck swelling
differential diagnosis will
include the thyroid, lymph
nodes, vascular, skin etc.
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/auto-immune
4. Vascular/degenerative
5. Neoplastic/para-neoplastic
6. Metabolic/endocrine
7. Drug-induced/poisoning
8. Deficiency diseases
9. Psychogenic
10. Idiopathic/cryptogenic
neoplastic/para-neoplastic, metabolic/endocrine, drug-induced/poisoning, deficiency
diseases, psychogenic and idiopathic/cryptogenic.
Rationally ordering a test or tests based on a practical ‘fast-and-frugal’
probability scoring
One major difficulty trainees’ exhibit after a patient encounter is coming-up with a
clinical probability for the possible diagnosis or differential diagnoses. Probability
estimation (based on the presence of risk factors and clinical findings) is crucial for
appropriate and rational diagnostic test ordering. An appropriate and practical
probability calculation or assessment methodology is the use of specific clinical
scoring or decision support tools such as the Well’s criteria for assessing the
probability of pulmonary thromboembolism. However, a more generic tool based on
the presence of a strong risk factor(s) for the problem or diagnosis and clinical
absence of alternative possibilities may be used for probability assessment. Thus the
presence of strong risk factor(s) for the problem or diagnosis coupled with the
absence of other significant competing differential diagnosis-supporting findings
qualifies the presumed diagnosis as high probability. On the other hand, if only one of
the two statements is true, the diagnostic probability is intermediate and if both are
negative, the probability is considered low. This ‘frugal heuristic’ [21, 22] which is
defined as the ability to reach a good probability assessment with limited
information, is thus fast and easily applicable. For example, a breast lump in a
30-year-old is unlikely to be cancerous. However, the presence of strong risk factor
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I. S. A. Hassan
such as a family history or hormone replacement therapy use and clinical absence of
symptoms and signs of infection or history of trauma, breast feeding etc., makes
cancer a high probability.
Tests are then ordered based on their sensitivity and specificity for the possible
diagnosis [23, 24]. A composite of a test’s sensitivity and specificity is the
likelihood ratio. Definitions of sensitivity, specificity and likelihood ratios are
shown in Table 3. The rules for appropriate ordering are based on the clinician’s
probability assessment. Tests with high specificity (usually more expensive) are
appropriate for high and intermediate-probability assessments, especially when the
considered diagnosis is life-threatening such as spiral computerized tomographic
pulmonary angiography for a high probability embolism. On the other hand,
highly sensitive tests (usually less expensive) are appropriate for low probability
patients and for screening such as d-dimer testing for patients with low probability
for pulmonary embolism, Tuberculin test, or faecal occult blood testing. The
mnemonics for these are SpIn: highly specific tests are useful for ruling-in the
diagnosis when positive and SnOut: highly sensitive tests are useful for ruling-out
the diagnosis when negative. As such, highly specific tests are useful when
positive and highly sensitive tests are negative. It is worth noting, however, that
highly sensitive tests may also help in prognostication and assessing response to
treatment when they are indeed positive. Brain natriuretic peptide is a highly
sensitive test. When negative, it almost completely rules out left ventricular failure
as a cause of pulmonary oedema [25]. However, the higher the reading, the worse
the prognosis [25]. Reduction of levels to normal confirms improvement with
treatment [25].
A comprehensive knowledge of the sensitivity, specificity and likelihood ratios of
commonly used tests is therefore essential.
Appropriate diagnostic labelling: the BESD diagnosis cognitive aid
The bedside clinical diagnosis, a etiological cause and severity score diagnostic
labelling (BESD) concept map for comprehensive diagnostic labelling has been
described previously [26]. Trainees should be able to comprehensively provide a full
label that explicitly portrays the three essential domains of diagnosis: bedside clinical
diagnosis, aetiology or precipitant, and severity. Guidelines unambiguously
recommend severity scoring for many clinical conditions, for example for
community-acquired pneumonia, bronchial asthma, acute pancreatitis and stroke.
Commonly, trainees have a tendency to incompletely provide a diagnostic label for
their patients. For example, labelling a patient with community-acquired pneumonia
as such without paying attention to the possible aetiology, e.g. influenza A or
bacterial pneumonia or severity e.g. the CURB-65 score, may inevitably result in
lower quality and deficient care and poorer outcomes.
The practical use of the four phases above in diagnosing a patient may be
conducive to a reduction in diagnostic errors, improved and rational use of diagnostic
tests and better guideline implementation.
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9. Schemes for decision making
327
Table 3 Sensitivity, specificity and likelihood ratios: definitions and examples
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
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
Likelihood ratio
The likelihood that a given test result would be
expected in a patient with the target disorder
compared with the likelihood that the same result
would be expected in a patient without that
disorder.
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 %
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 %
Example A raised jugular venous pressure (JVP) in
a patient with a history suggestive of congestive
heart failure (CHF) has a positive likelihood ratio
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
In general, a positive likelihood ratio of 4 or more is
useful in ruling-in the target disorder. A negative
likelihood ratio of0.3 is useful in ruling-out the
target disorder
Step 3: immediate therapeutic interventions: the 5S cognitive aid
Similar to the BESD model, the 5S concept map has also been described
previously [26]. The 5S therapeutic concept map (site of care, symptomatic
treatment, supportive care, specific care, speciality referral) is considered a simple
cognitive aid that will assist the practising physician (especially front-line staff in
the emergency room) in constructing an evidence-based, patient-centred, timely
and comprehensive therapeutic plan. Guidelines unambiguously dictate sites of
care for specific disease severity scores or categories, e.g. in a patient with diabetic
ketoacidosis and significant hypokalaemia or hyperosmolarity. Prompt provision of
symptomatic treatment is important as it directly alleviates patient discomfort.
Symptom relief is regrettably not regularly ordered by medical staff. An excellent
example is the poor use of analgesics in the acute care setting, referred to as
oligoanalgesia. Similarly, prompt use of supportive care to improve physiological
derangements before damage becomes irreversible and until the precipitant is
brought under control by its specific intervention may be life-saving, e.g. oxygen
therapy in hypoxic patients, intravenous fluids in patients with hypovolaemic
shock, or sodium bicarbonate in severely acidotic patients. Correctly providing
specific care to treat the primary cause or aetiology is a fundamental step in patient
care. Guidelines recommend early speciality or sub-speciality referral for specific
acute illnesses, e.g. patients with acute coronary syndromes or significant upper
gastrointestinal haemorrhage and associated co-morbidities need to be referred
early to their respective specialities.
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Table 4 A case scenario illustrating the use of the ‘technical’ expert summary, BESD, pathological
differential diagnosis and 5S therapeutic interventions
• 67-year-old male
• Bird/pigeon breeder, smoker
• 3-day 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 39.1 °C
• BP 86/50 mmHg, 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-day history of productive cough, dyspnoea and
left pleuritic chest pains
Clinically confused, cyanosed, febrile, tachypnoiec and hypotensive with signs of left lower zone
consolidation
1. Bedside-clinical diagnosis
Community acquired pneumonia with septic shock
2. Cause/precipitant
Chlamydia psittaci
Aetio-pathological differential diagnosis
Other Infections: e.g. avian flu, cryptococcal infection
Inflammatory e.g. collagenosis, allergic alveolitis
Vascular e.g. pulmonary embolism
Neoplastic, drug-induced etc.
3. Severity
Life-threatening (CURB-65 = 4)
4. Site of care
ICU
5. Symptomatic
Analgesia, anti-pyretic
6. Supportive
Oxygen, intravenous fluids
7. Specific
Antibiotics
8. Speciality referral
Intensive therapy unit, pulmonary service
Step 4: the ACT cognitive aid: assessment of response to treatment, criteria
for discharge and timing of follow-up
It is critical and imperative that once a diagnosis is reached and a therapeutic
intervention is instigated, at least three other practical actions are undertaken. Firstly,
the assessment of response to treatment: a satisfactory response to one’s therapeutic
intervention is a solid proof that the diagnosis was correct and appropriate. Usually,
assessment of response is based on both subjective and objective measures. The latter
include either clinical criteria such as fever, vital signs etc. or laboratory and imaging
and other investigations. Failing to internalize clear and solid criteria for home
discharge or other patient disposition areas results in unnecessary and longer hospital
stays. The majority of patients who are discharged from hospital will require followup visits. These are required for both disease and drug monitoring. Appropriateness
and timeliness of such visits may assist in reducing the readmission rates.
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11. Schemes for decision making
329
Diagnostic & Therapeutic Decision Maps
History & Physical
Hypothetico-Deductive:
Differential Diagnosis:
Pathological, Anatomical or
Physiological
Pattern-Recognition
Heuristics/LowFidelity e.g. Chest
pain radiating to
the left arm in a
patient with IHD
High-Fidelity e.g.
Herpes zoster,
Acromegaly etc
High (2 YES) or Intermediate (1
YES) Pre-test Probability:
1. Strong Risk factor for the
condition
2. No alternative Diagnosis
Low Pre-test Probability:
1. No strong risk factor for the
condition
AND
2. Likely alternative Diagnosis
Highly Sensitive
(Screening ) Test
(SnOUT)
Highly Specific
Diagnostic Test
(SpIN)
(Optional)
Positive
Negative
Positive
No/Unavailable
Highly Specific
Diagnostic Test
Highly specific
diagnostic test
(SpIN)
Diagnosis
ruled out
Positive
Diagnosis Made
Bed-side Clinical
Diagnosis
Etiological
Diagnosis
Severity
Therapeutic Intervention or Trial
Site of Care
Symptomatic
Care
Supportive
Care
Specific Care
Specialty Referral
Assess Response, Criteria for Discharge, Follow-up
Cure or Improvement confirms the diagnosis
Fig. 1
Diagnosis and therapy cognitive maps
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I. S. A. Hassan
Final remarks
Apart from individual or trainee-directed cognitive interventions, system-based
interventions for reducing diagnostic and therapeutic errors and deficiencies must
similarly be put in place. Such system tools include curricula for regular training and
assessment of staff in decision-making skills and bias recognition, use of reminders
such as clinical pathways, protocols, order sets, checklists, use of computerized
decision support tools, mechanisms for error detection and rectification and a general
improvement in knowledge access by all staff [12, 13, 27, 28].
Table 4 portrays a case scenario illustrating the use of the expert summary, BESD,
pathological differential diagnosis and 5S therapeutic interventions schemes.
Figure 1 is a graphic summary of approaching a diagnostic challenge and the
immediate therapeutic interventions and further care inputs.
Essentials
1.
2.
3.
Cognitive conceptual deficiencies in decision-making are recognized as an
important cause of poor patient care.
Unlike novices, experts develop robust and complex schemes that facilitate the
provision of higher-quality and time-efficient care inputs.
Empowering trainees with explicit, generic schemes of care early in their clinical
career may hasten their novice to expert critical thinking, problem-solving and
decision-making skills acquisition as well as improve their use of evidencebased medicine.
Conflict of Interest None.
Funding None.
Open Access This article is distributed under the terms of the Creative Commons Attribution License
which permits any use, distribution, and reproduction in any medium, provided the original author(s) and
the source are credited.
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Author Biography
Imad Salah Ahmed Hassan is an internist with a significant involvement in both undergraduate and
postgraduate training. He chairs a committee responsible for improving competency-based clinical
training. He has been chosen on three occasions as Best Tutor in the Residency Training Programme. He
has been instrumental in developing several new models of training as well as incorporating them in the
Residency training programme.
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