NR 569 Differential Diagnosis in Acute Care Midterm Exam - Q & A Comprehensive Patient Assessment - Appropriate for new patients in the office or
... [Show More] hospital. - Provides fundamental and personalized knowledge about patient. - Strengthens the clinician-patient relationship. - Helps identify or rule out physical causes related to patient concerns. - Provides a baseline for future assessments. - Creates a platform for health promotion through education and counseling. - Develops proficiency in the skills of physical assessment. Focused Patient Assessment - Appropriate for established patients, especially during routine or urgent care visits. - Addresses focused concerns or symptoms. - Assesses symptoms restricted to a specific body system. - Applies examination methods relevant to assessing the concern or problem as thoroughly and carefully as possible. Subjective Information - The clinical record from the Chief Complaint (CC) through the Review of Systems (ROS) is considered SUBJECTIVE information. - Includes symptoms which are health concerns the patient tells the provider. - Includes feelings, perceptions, and concerns obtained from the clinical interview. - Examples: complaints of sore throat, headache, or pain. Objective Information - All physical examination, laboratory information and test data are objective data. Components of Comprehensive Adult Health History - Initial information (Identifying patient information/source/reliability) - Chief Complaint(s) - History of Present Illness - Past Medical History - Family History - Personal/Social History - Review of Systems (ROS) SNAPPS method - Summarize the history and findings. - Narrow the differential diagnosis to two to three possibilities. - Analyze the differential by comparing and contrasting the possibilities. - Probe the preceptor by asking questions about alternative approaches or uncertainties. - Plan the management of the patient's health issues. - Select an issue from the case for self-directed learning. Creating a Differential Diagnosis Hoofbeats = Horses NOT Zebras - The differential diagnosis process involves using clinical reasoning to distinguish between two or more conditions that share similar signs and symptoms. Based on the CC the NP gathers information through PMH (subjective data) and physical examination (objective data) to establish a broad list of common & uncommon diagnosis. As the provider collects more data, competing hypotheses are either confirmed, disproved, or their priority changes. Steps for Creating a Differential Diagnosis 1. Initially start with a broad list of diagnoses until further information or data is obtained. 2. List your top diagnosis FIRST followed by other potential diagnoses for a specific problem *but keep it problem oriented until you have an actual diagnosis.* 3. Aggressively prioritize work up of the most likely and most harmful (ie, life threatening) diagnoses under consideration. 4. Prioritize the work up of ACUTE and REVERSIBLE diseases followed by CHRONIC and IRREVERSIBLE (eg, delirium r/t a medical cause vs. chronic, progressive dementia). 5. As information or data that effectively rules out a particular diagnosis for a chief complaint becomes available, remove that diagnosis from your list & focus your attention on remaining possibilities. 6. Once a diagnosis has been confirmed, the problem list should be diagnosis-oriented rather than problem-oriented. Pertinent Positive - Symptoms or signs that are present that you would expect to find if a possible cause for a patient's problem were true, which then supports the diagnosis. Pertinent Negative Expected symptoms or signs that are not present, facts that you would expect to find if a possible cause for a patient's problem were true, which then weaken this diagnosis by their absence. Principles of Good Documentation *Checklist to Ensure a Quality Clinical Record.* 1. Is the organization clear? - Make the headings clear. - Accent your organization with indentations and spacing. - Arrange the HPI in chronologic order, starting with the current episode, the filling in relevant background information. 2. Does the included information contribute directly to the Assessment? - Spell out the supporting evidence, both positive and negative, or each problem or diagnosis. Make sure there is sufficient detail to support your differential diagnosis and plan. 3. Are pertinent negatives specifically described? - Often portions of the history or examination suggest that an abnormality might exist or develop in that area. For example, for the pt with notable bruises, record the "pertinent negatives", such as the absence of injury or violence, familial bleeding disorders, or medications/nutritional deficits that might lead to bruising. 4. Are there overgeneralizations or omissions of important data? - REMEMBER THAT ANY INFORMATION NOT RECORDED IS INFORMATION LOST. 6. Is there too much detail? - Is there excess information or redundancy? Make your descriptions concise. You can omit unimportant structures even though you examined them, such as normal eyebrows and eye lashes. CONCENTRATE ON MAJOR NEGATIVE FINDINGS such as "no heart murmurs" rather than negative findings unrelated to the patient's complaints. 7. Is the written style succinct? Are phrases, short words, and abbreviations used appropriately? Is data unnecessarily repeated? - Using words or brief phrases instead of whole sentences is common, but abbreviations and symbols should be used only if they are readily understood. Omit unnecessary words. Describe what you observed, not what you did. 8. Are clear descriptions or images included whenever possible? - To ensure accurate evaluations and future comparisons, describe findings Evaluation and Management (E/M) codes Evaluation and management (E/M) coding involves the use of CPT codes ranging from 99202-99499. These represent services by a provider in which the provider is either evaluating or managing a patient's health. Evidence-Based Medicine - The conscientious, explicit, judicious and reasonable use of modern, best evidence in making decisions about the care of individual patients. PICOT question - A mnemonic derived from the elements of a clinical research question - Patient, Intervention, Comparison, Outcome and Time. The PICOT process begins with a case scenario, and the question is phrased to elicit an answer. Sensitivity Sensitivity refers to a test's ability to designate an individual with a disease as positive. - A sensitive test correctly identifies patients do who have the disease in question. Tests with high sensitivity are ideal screening tests to discover as many patients as possible with the disease, frequently a tradeoff of increased false positive results. **Confirmatory testing may require a more specific test.** Sensitivity Formula - To calculate sensitivity the number of patients who do have the disease and test positive (true positive = TP) is divided by all who have the disease, including those who falsely test negative (false negative = FN) - TP/(TP + FN) Specificity - Specificity refers to the ability of testing to recognize patients who do not have the disease. - For example, D-Dimer has high sensitivity and will be positive in most cases of PE; however, this comes at the cost of a high false positive rate due to low specificity. A confirmatory, more specific, imaging test may be required to make the diagnosis. Specificity Formula - To calculate specificity, the number of patients who test negative and do not have the disease (true negative = TN) is divided by the total number without the disease, including those who falsely test positive (false positive = FP). - TN/(TN + FP) SPIN & SNOUT SPecific test rule IN disease (SPIN) while SeNsitive tests rule OUT disease (SNOUT). Positive Predictive Value (PPV) - Positive Predictive Value (PPV) reports the probability that a patient has the disease after testing positive for it. Positive predictive value is markedly dependent on the prevalence of the disease in question. - TP/(TP + FP) Negative Predictive Value (NPV) - Negative predictive value (NPV) describes the probability that a patient does not have the disease following a negative test result. Both positive and negative predictive values are dependent on the prevalence or pretest probability prior to testing. - TN/(TN + FN) Pretest Probability Pretest probability percentage represents them probability of a specific pathology for a patient prior to initiating further diagnostic testing. Pretest probability may be the prevalence of the disease in question in the population. At any point in the diagnostic work up, the clinician may pause and estimate the prevalence or pretest probability of disease in light of what information is known about the patient. The pretest probability of clinical gestalt is frequently delineated as low, intermediate, and high probabilty. Positive Likelihood Ration - The positive likelihood ratio is the likelihood that a patient with the disease tests positive compared to the likelihood that a patient without the disease tests positive. If a test result is positive and the likelihood ratio is greater than 1, then it is more likely than chance that the patient has the disease. However, if the likelihood ratio for the test is less than 1, then it is less likely the patient has the disease. Negative Likelihood Ratio - The negative likelihood ratio is the likelihood that a patient with the disease tests negative compared to the likelihood that a patient without the disease tests negative. Five Densities of Radiographic Densities 1. Air ([MOST RADIOLUCENT] blackest - least dense) 2. Fat 3. Water (soft tissue) 4. Mineral (Bone) 5. Metal ([MOST RADIOPAQUE] - whitest- MOST DENSE) **Listed from least to most dense** How does air appear on x-ray? - Air appears the blackest on radiograph *ABSORBS THE LEAST XRAY* How does fat appear on x-ray? - Fat appears as the darkest shade of GREY - **Lighter than air but DARKER than soft tissue/fluid** How do soft tissue and fluids appear on x-ray? - Both fluid and soft tissue have the same density on conventional radiographs. **It is impossible to differentiate blood from muscle inside the heart on x-ray.** How do minerals (specifically calcium = bone) appear on x-ray? - Most dense NATURALLY occurring material - absorbs most of the x-ray - lightest shade of grey. How does metal appear on x-ray? - Metal is the most dense material viewed on x-ray - absorbs all of the x-ray - BRIGHTEST WHITE [Show Less]