USMLE Step 1 Review/Clinical decision-making
Clinical decision-making is a broad subject area covering biostatistics and epidemiology. Also covered are an approach to the patient interview, the physical examination, and the establishment of a differential diagnosis.
Patient interview
[edit | edit source]The patient interview, or patient history, consists of:
- chief complaint (CC)
- history of present illness (HPI)
- medications
- allergies
- past medical history (PMH)
- past surgical history (PSH)
- social history
- family history
- review of systems (ROS)
Eliciting the HPI and exploring symptoms is done systematically:
- Onset of pain (what was the patient doing when the pain started?)
- Palliative or Provocative factors for the pain
- Quality of pain (burning, stabbing, aching, etc.)
- Radiation (up to jaw, down left arm, etc.)
- Severity of pain (usually 1 - 10 scale)
- Timing of pain (eg: after meals, in the morning, how long it lasts, etc.)
Similarly:
- Site of pain
- Onset of pain
- Character of pain (dull, sharp, aching, stabbing, tearing etc.)
- Radiation of pain (eg. central abdominal pain radiating to Right Iliac Fossa)
- Associated factors (eg. nausea/vomiting)
- Timing of pain/duration
- Exacerbating/alleviating factors
- Severity of pain (usually 1 - 10 scale)
Alternatively:
- Aggravatiing and Alleviating factors
- Severity
- Character, quality
- Location
- Associated symptoms
- Setting
- Timing
(ASCLAST means let the patient talk first, then ask him/her specific questions.)
to make a differential diagnosis for a problem
use the word VINDICATE
V vascular
I inflamation / Infection
N Neoplasm
D Degenerative
I Intoxication
C collagen disease / congenital disease
A autoimmune disease
T Trauma
E endocrine
Differential diagnosis
[edit | edit source]The patient interview rarely indicates a single diagnosis; rather, usually there is a list of potential diagnoses, called a differential diagnosis. Systematically thinking through a differential diagnosis ensures that all possibilities are considered. The mnemonic VITAMIN C is commonly used to accomplish this:
- Vascular
- Infectious
- Traumatic
- Autoimmune
- Metabolic
- Idiopathic/iatrogenic
- Neoplastic
- Congenital
Admission orders
[edit | edit source]When admitting a patient to the hospital, several orders must be written. The DAVE WILMINGTON mnemonic helps to accomplish this systematically:
- Diet
- Activity
- Vital signs (how often)
- Excrement (test urine / stool)
- Weight (how often to monitor)
- Input/output (eg, "strict ins/outs")
- Labs (what, how often)
- Meds (which, route, interval)
- I V fluids (what and at what rate)
- Nursing care (e.g. position, wound care, up in chair, ostomy care etc)
- General care (e.g. Physical Therapy, Respiratory Therapy etc)
- Tests (X-ray, EKG, EEG etc)
- Observe for reaction, seizure, neuro exams
- Notify parameters (e.g. Temp > 100 / respiration changes)
The ADC VAAN DIML mnemonic is also used commonly:
- Admit (23 hours, full admit, service of attending,...)
- Diagnosis
- Condition ("Stable", "Guarded", etc.)
- Vitals (post-op, routine, q 1 hour, etc.)
- Allergies
- Activities (Strict bed rest, fall precautions, ad lib, bathroom privileges, etc.)
- Nursing (Strict I&O's, Daily weights, Call P.R.N. whatever, etc.)
- Diet (NPO, Regular, Clears - advance diet as tolerated, 2000 cal ADA, renal, etc.)
- IV fluids (D5 1/2 NS c 20 KCL at 110 ml/hr, LR @ 100 ml/hr, etc.)
- Meds (scheduled and PRN's)
- Labs and x-ray (CBC in AM, PCXR in PACU, etc.)