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UC NURS 8026 - DD Exam 1 Study Guide

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1. Diagnostic Reasoning Types:Definition:- Dynamic thinking process that leads to the identification of a hypothesis that best explains the clinicalevidence.- A method of exploring a patient problem using an approach that is systematic and organized, resultinginto the generation of a hypothesis.Factors that affect reasoning:A. Patient driven- increasing acuity- poor historians- altered mental status- multisystem disease: acute & chronic - people have acute exacerbations of chronic diseases:COPD, CHF, and CAD.- Multiple complaintsB. Clinician driven (novice vs expert)- limited experience- knowledgebase- continuous review of data- uncertainty of data - random high lab value (CMP/BMP). Can't understand why value elevated inthis patient. Sometimes you need to redo the test. Look at patient and what data says to see if theymatch.- demands for cost effectiveness and speedA. Probabilistic Reasoning (if A + B = C):- associations between clinical data that trigger the potential presence of a disease- demographic description- presenting manifestations- signs & symptoms- = a probable causeEx. Elderly pt with confusion. Hx: 6 weeks ago pt was rational and independent. Fell and hit head,loosing consciousness for little bit of time. Fine the next day. Possible "Chronic subdural hematoma".B. Causal Reasoning:- Based on cause & effect relationship between clinical data- Corroboration presentEx. Someone with high triglycerides at risk for pancreatitis/CAD. C. Deterministic Reasoning (guides): things you know exist like ABC = airway breathing circulation- depends on knowledge that exists as unambiguous rules- outline routine clinical practice- diagnostic algorithms: ACLS- list of rulesD. 2 patterns of diagnostic reasoning: 1. Backward reasoning: generates hypothesis then tries to acquire data to uphold it - seen with novice clinician- lack of knowledge inhibits construction from data alone- inefficient- earlier ROS may help trigger development 2. Forward reasoning: uses data item or set to generate hypothesis - characteristic of experts - dependent on solid knowledge of symptomatology - highly efficient 2. Understand diagnostic process• Combination of systematic analysis & intuitive knowledge• Systematic analysis involves the use of explicit knowledge:1• knowledge of physical or psychological states, conditions, or diseases & their associated probabilities, pathophysiological mechanisms & clinical manifestations.• Different types of reasoning used throughout the processA. Dependent factors:- knowledge of conditions, states, or diseases - listed on illness scripts- information re: epidemiology, patho, mechanisms, & associated clinical manifestations- expert knowledge of association between conditions & clinical manifestations- recognition of patterns in S/S of disease: involves the simultaneous ability to recall the pattern for adisease and to distinguish between manifestations of one disease from another. (learned in explicit knowledge, things taught + grounded in evidence)Ex. Two 50-year-old men come in with CP. MI or Reflux, how to determine between "CC"? - Patient 1: hx of hyperlipidemia, DM, and HTN father died of MI @ 50. He first noticed CP when he was shoveling (usually a couch potato). = ischemia.- Patient 2: first noticed burning/CP at night when he lays down after eating. Wakes up with awfulsour taste in mouth. Eats a lot of fatty/spicy foods = GERD.** Can't fit into a disease/prototype**- Expert has prototypes that can be used as a paradigm for future cases - illness scripts:Consisting of 3 main categories: 1) Predisposing conditions: risk factors/family hx2) Pathophysiological insult: what happens to rest of body when someone has HTN/DM/Asthma3) Clinical consequences: what you see when not cared for appropriately.- Heuristics (rules of thumb) are mental strategies that provide short-cuts but can also lead to errors- Atypical clinical presentations of common diseases occur more frequently than typical presentations of a rare disease - Implication that 1 disease process is present that explains all manifestationsB. Influences on diagnostic reasoning: • Maxims are guiding principles used by experts • Common things occur commonly• Real disease declares itself - real diseases will continue to be there• Follow-up is everything - Is this what I thought it was? Did I tx appropriately? Give enough medication? If both yes - then go back to drawing board and figure out what else is going on. C. Differential Diagnosis: process Prioritize the list: (prevalence of dx in community, Lime Dx is common in Rocky Mountains not FL)• Possibilistic• Probabilistic: consider most likely w/highest pretest probability• Prognostic: most serious first• Pragmatic: most responsive to treatment Ex. If pt found unconscious: give D50 and he perks up.Formulation includes several factors: (not asking good questions to formulate the list)- Consider most life threatening first- Serious consideration to common illness, age & gender- Occurrence & prevalence of rare disease Common errors in formation:- Lack of familiarity w/S&S- Prevalence- Fail to form exhaustive listInformation generators: - History & PE contribute most info- Dx tests are useful only to rule in or out3. Definitions of types of knowledgeA. Explicit knowledge can be systematically:- Described, analyzed, measured and taught.- Provides foundation on which reasoning takes placeB. Tacit knowledge (intuitive) depends on previous experiences that you've had:2- Possessed w/out conscious awareness or Intuition- Assists in the ability to analyze & make rapid decisions- Unconsciously learned thru observation- Quantitative & qualitative - built on to explicit knowledge- Combination of both = expertise4. Differentiate between sensitivity and specificitya) Sensitivity - confirms presence of dxi) What proportion of those patients who have the disease will have an abnormal (+) result = True +b) Specificity - confirms absence of dxi) What proportion of those patients who do not have (absence) the disease will have a normal (-) result = True -Results Disease PresentDisease AbsentPositive A - True + B - False +Negative C - False - D - True -Bayes' Theorem: similar to sensitivity & specificity - "given as many relevant factors as possible what is the probability (likelihood)?"5. Probability/Likelihood ratioA. Pretest probability:• probability that the patient has the disease before result is known•

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