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 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 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 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.)