Chapters 3, 4, 5,7,8,9,11, 22
Principles of Primary Care
Diagnostic reasoning can be seen as a kind of critical thinking. Critical thinking involves
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process of questioning one’s thinking to determine if all possible avenues have been explored
and if the conclusions that are being drawn are based on evidence. Diagnostic reasoning then
includes a systematic way of thinking that evaluates each new piece of data as it either supports
some diagnostic hypothesis or reduces the likelihood of others.
The type of data that you collect depends on the type of visit. Most visits are episodic or
problem-focused where 1 or 2 specific issues need to be addressed. One thing I want to point out
is that the information in the H&P should only be relevant to the complaint or problems that you
are addressing. So, a patient with only a skin complaint does not need a full H&P. Rather, a
focused history and exam as it relates to the skin complaint or associated symptoms should be
recorded.
First, I want to go over two important, distinct concepts that seem to be an area of confusion for
many students: subjective and objective findings. We will discuss these in more detail when we
introduce the SOAP note lecture.
To start, subjective information is what the patient:
1) reports,
2) complains of; or
3) tells you in response to your questions.
Examples of subjective information include the following:
• Constitutional: fever, chills, lethargy, weight loss or gain, and so on
• HEENT: headache, blurred vision, otalgia, sore throat, and so on
• Neck: swollen lymph nodes, and so on
• Lungs: SOB, cough, wheezing, and so on
These are all examples of subjective information. Subjective information is the S part of the
SOAP note, which includes CC, HPI, and ROS, as these are all things that the patient reports to
you in an interview.
Objective information is what you can see, hear, or feel as part of your clinical exam. It also
includes laboratory data and test results. Examples of objective information include the
following:
• Constitutional: well-developed, well-groomed, thin, cachectic, obese, and so on
• HEENT: Normocephalic, PERRL
• Neck: anterior cervical lymph nodes are swollen and tender
• Lungs: clear, wheezing in RLL, bronchospastic cough
• Results: you might list the CBC, strep test, U/A, CXR, CT, and so on
Objective information is the “O” part of the SOAP. Eliciting a detailed patient history through
open-ended questioning and active listening offers critical clues to determining a diagnosis.
Obtaining a meaningful history involves collecting subjective information and organizing it into
meaningful chunks of knowledge. Data acquisition in history taking is most effective if it is
hypothesis driven. In other words, when the information selected and gathered is related to the
list of possible diagnoses. Hypothesis-driven data means that data that would confirm or
disprove a specific hypothesis are specifically sought and recorded. However, obtaining data that
fit one possible problem is not enough. Competing hypotheses must be ruled out by seeking
additional data, and the provider needs to consider that the priority list of hypotheses may change
based on new information.
For example, symptoms of runny nose may be due to a viral infection. If in the history- taking
the provider specifically asks if these symptoms have occurred before and the patient replies,
“Yes, this also happened 2 weeks ago,” the likelihood of a viral infection decreases and the
likelihood of an allergy increases. In other words, your hypothesis for the etiology of rhinitis has
now changed.
The chief complaint (CC) is a one-to-few word statement identified by the patient as the reason
for their visit to you today. Try to identify the chief complaint in this scenario:
Johnny, a 5-year-old, is brought to your office by his mother. The mother reports that the school
nurse called because Johnny said he had a tummy ache. Several other students in the school also
have complained of some GI symptoms. He did not throw up, but he says he feels like he could.
In this case, an acceptable CC would be nausea or “tummy ache.” It’s short and to the point. You
will expand on information about the chief complaint in the history of present illness (HPI).
The HPI is a detailed breakdown of the CC, written out as the OLDCARTS acronym. Each letter
in the acronym represents important information about the CC, which will help you to develop a
differential diagnosis. The HPI is focused on the CC only, so each letter of the acronym should
address that one issue. Any additional information that you feel is pertinent to report in the case
but is not directly related to the CC should be reported in the ROS.
HPI
O: Onset of CC
L: Location of CC
D: Duration of CC
C: Characteristics of CC
A: Aggravating factors for CC
R: Relieving factors for CC
T: Treatments tried for CC
S: Severity of CC
There are two things I want to point out here. Do not get confused on duration. Duration is not
referring to the onset of the symptom. Rather, it is an assessment of whether the symptom is
constant or if it comes and goes. Also, don’t forget to ask about severity. Severity refers to the
level of pain (such as reported on a pain scale) or how the symptom has impacted the patient’s
ability to go to school, to go to work, or to perform their daily routine. This should be included in
every HPI.
Be sure to watch the video lecture on the ROS, which is again, assessment
of subjectiveinformation.
Differential diagnosis, or differential, is a list (single) of plausible diagnoses (plural) that fit the
historical and clinical presentation of your patient in order of priority. This is different than the
problem list, which is a list that includes all of the active medical problems for the patient. You
will be seeing these in your clinical rotations, but for the purposes of your first clinical course,
we will not be putting together problem lists. The focus in this course is on how to formulate a
differential diagnosis. There is a separate video lecture on the differential diagnosis for you to
view this week which presents the concept of formulating a differential diagnosis in a
meaningful way.
Diagnostic tests can be used to confirm or to rule out hypotheses. They may also be used to
screen for conditions or monitor the progress in managing a chronic condition. Diagnostic tests
vary in usefulness based on sensitivity, specificity, and predictive value.
When we describe the specificity of a test, we are referring to the ability of the test to correctly
detect a specific condition. If the patient has the condition but testing is negative, we describe
this as a false negative. If the patient does not have the condition but the test result is positive,
this is considered to be a false positive test.
When a test is very sensitive, we mean it has few false negatives. The higher the sensitivity, the
lesser the likelihood of a false negative. A sensitivity of 99% means that it is very unlikely for a
false negative result.
In a perfect world, a test would have 100% specificity and sensitivity, but we know that it is not
the case. Therefore, it is important to consider the specificity and sensitivity of a test when
considering its usefulness in ruling your hypothesis in or out.
Predictive value is the likelihood that the patient actually has the condition and is, in part,
dependent upon the prevalence of the condition in the population. If a condition is highly likely,
a positive test result is more likely to be accurate. If a condition is very unlikely, a positive test
needs to be questioned and perhaps additional testing would need to be done.
When deciding whether or not to order a test, five things must be considered.
• Cost
• Convenience
• Sensitivity
• Specificity
• Risk of missing a condition (predictive value)
In today’s healthcare system, patients are encouraged to be proactive and informed members of
the healthcare team. One method that is advocated by popular groups such as AARP, the NIH
and the CDC is for patients to create a list of questions or issues for their provider visits. Lists
can be challenging for providers because many patients have the unrealistic expectation that their
provider will address every item on the list. You will see this frequently in your practicum
rotations. The reality is that the medical office is still a business, and time constraints often
prevent providers from addressing every issue in one visit.
Prioritizing the patient’s needs while maintaining the allotted time requires a patient-centered
communication approach. Although you may not be able to cover the list in its entirety, this
approach acknowledges to the patient that you hear their concerns and together have developed a
plan to address them. This tactic not only improves patient satisfaction but helps keep the
provider on schedule. In the next few slides, we will be discussing a useful approach to
prioritizing a patient’s list. Keep in mind that these are suggestions and not rules. At the
beginning of each practicum rotation, I encourage you to discuss with your preceptor how he/she
deals with this issue. Some offices may have a policy in place or the provider may have a
personal preference in handling prioritization of patient’s lists. These suggestions may not be the
best approach for the practice setting that you are currently in but may be useful in another office
or in your own practice.
Mutually negotiate what to cover during the visit. If the patient’s list is too long or does not
match your own priorities for the visit, you will need to negotiate which items you will address at
the current visit. The key to the negotiating process is to use positive language. So, instead of
saying “we don’t have enough time to discuss all of these”, a better approach would be to say “I
would like to cover as much as we can from your list, but I also want to take a few minutes to
talk about your (diabetes, HTN, COPD, etc).
Make a plan for follow-up. Mutually set an agenda and time frame for the next visit. Recap what
you were not able to address at this visit and what you intend to go over the next time. If a
patient is overdue for an annual physical, you might make the recommendation that one is
scheduled since more time is typically allotted for these visits. Be sure to document this plan in
your note as a reminder to you for the next patient visit.
All healthcare providers are called to provide evidence-based care, which involves providing
care and making treatment and screening choices based on current research findings. Generally,
EBP refers to using research findings from multiple studies that are convincing enough that a
consensus is formed recommending the findings be used for clinical decision-making or practice
guidelines.
EBP also involves inclusion of patient and provider preferences, patient values, and cultural
considerations in the clinical decision-making process. Guidelines should be followed in the
majority of cases unless there is a clear rationale for deviating from them to serve the particular
needs of the patient.
There are some examples of Clinical Practice Guidelines/Evidence-Based Guidelines developed
by organization or agencies that I have listed here. Some examples are:
For allergen and immunotherapy, the American Academy of Asthma and Allergy group is one
example. The Infectious Disease Society of America is also another group that puts out clinical
practice guidelines.
The End
Health Promotion: Risk Factors and Influences
Hi. In this brief presentation, we will be discussing the importance of influences on health
promotion. There is an opportunity for disease prevention, screening for high-risk problems, and
health promotion at every visit. There are three levels of prevention: primary, secondary, and
tertiary. Focusing healthcare efforts on all three levels of prevention is important, but primary
prevention has become the ultimate goal of health promotion.
Primary prevention is the prevention of disease. Examples: Health education, immunizations, use
of sunscreen and seatbelts, nutrition counseling, weight control, stress reduction, exercise, etc.
Secondary prevention is the detection of a disease through its very early stages through early
screening. Examples of this include skin cancer and breast cancer screening, testicular selfexam, HTN screening, cervical cancer screening, pediatric developmental screening, and Fecal
Occult Blood samples (FOB).
Tertiary prevention is the restoration of health after illness or disease has already occurred in
order to prevent further sequelae of the disease and complication. Some examples of this include
dialysis and chronic kidney disease, chemotherapy in cancer, biologics in autoimmune disease,
and statins for hyperlipidemia.
The identification of risk factors is an essential component of health promotion. The key
components to effective health promotion are to screen patients for potential known risk factors
and to intervene when appropriate. Obviously, some risk factors are modifiable, and some are
not. Nonmodifiable risk factors include age, gender, and family history, whereas modifiable risk
factors include weight, level of physical activity, elevated cholesterol and blood pressure, stress
level, and smoking. Early identification of both modifiable and nonmodifiable risk factors are
integral so that patients also with modifiable risk factors can make changes to affect more
favorable outcomes with a disease.
One factor that influences health promotion is health literacy. Health literacy can be described as
the degree to which individuals have the capacity to obtain, process, and understand basic
information and services needed to make appropriate healthcare decisions. Health literacy
includes reading skills and comprehension, writing, listening, speaking, and conceptual
knowledge. Assessing health literacy levels should be part of your daily practice so that you can
identify patients at risk for misunderstanding instructions and for those who may not have the
ability to adhere to recommendations.
Intro to Billing and Coding
In this presentation, we will be discussing a very basic overview of billing and coding.
My name is Dr. Tracy Murray.
Although an entire day can be spent on this topic, this lecture is designed to teach you the basic
elements that you will need in order to determine a level of service for each visit, which
subsequently determines the level of payment to the provider. I’m sure I do not need to tell you
that payment is very important in any business, even healthcare. Whether in a solo practice or
group practice, providers must generate income to keep the practice afloat and, ideally,
profitable. Unless you will be operating a nonprofit practice that is funded entirely by donations,
there are universal rules that you must know in order to correctly bill for your services. I
encourage you to speak more to your preceptors about the billing process while in your clinical
setting.
So you might ask, why is this important to me as a student? Understanding the levels of office
visit billing is important to you as a student because this information should be reflected in your
log of patient encounters and can be reviewed by faculty to ensure that you are seeing patients of
all ages and complexities. We will get more into documentation of your encounters in the next
lecture, but just know that it is important to accurately document the types of patients that you
see in your clinical rotations.
Now, let’s talk about the importance of documentation. The written history and physical (H&P)
serves several purposes.
1. It is an important reference document that gives concise information about a patient's
history and exam findings.
2. It outlines a plan for addressing the issues that prompted the visit. This information
should be presented in a logical fashion that prominently features all data immediately relevant
to the patient's condition.
3. It is a means of communicating information to all providers who are involved in the care
of a particular patient.
4. It is an important medical-legal document.
5. It is essential in order to accurately code and bill for services.
Currently in the United States, our healthcare system operates on a fee-for-service model. This
means that a provider is given a set amount of monetary reimbursement for a specific visit or
procedure performed that is adjusted for geographical location. Payment is dependent, though,
on showing the necessity for the service provided to the payer by means of accurate
documentation. Now, a payer can be a public or private entity. Private entities include insurance
companies that you’re contracted with in your office, whereas public payers include Medicare
and Medicaid.
Medical coding is the use of codes to communicate with payers about which procedures were
performed and why. Medical billing, on the other hand, is the process of submitting and
following up on claims made to a payer in order to receive payment for medical services
rendered by a healthcare provider.
In order to send a claim (or bill) to a payer such as Medicare, the provider’s documentation must
be translated into alphanumeric codes and transferred to the payers. Keep in mind that only codes
are submitted for each individual claim, which means you are not faxing your actual
documentation over. Therefore, you want to be sure that the codes accurately reflect the type of
service that you provided.
There are two different designated coding systems that are used today, which were developed as
a means to standardize terminology and simplify medical records. The first system is the
Common Procedural Terminology (CPT) system, and the second system is the International
Classification of Diseases method of coding and that’s known as the ICD system.
The CPT system offers the official procedural coding rules and guidelines required when
reporting medical services and procedures performed by physician and nonphysician providers.
CPT codes are recognized universally and also provide a logical means to be able to track
healthcare data, trends, and outcomes. Each service or procedure is represented by a five-digit
code that is presented in six sections, including
• evaluation and management;
• anesthesiology;
• surgery;
• radiology;
• pathology; and [Show Less]