Clinical Approach to Patients

Tanarat Choon-ngarm MD

Clinical decision making

Clinical reasoning Use of cognitive short cuts
1. 2. 3.

Representativeness heuristics Availability heuristics Anchoring heuristics

Diagnostic hypothesis generation

A diagnostic hyposthesis sets a context for diagnostic test to follow and provides testable predictions Expert clinicians do not follow a fixed pattern in patient examination Negative findings are often as important as positive ones

Data collection
History Physical examination Investigations which depend on the hypothesis generated from clinical findings Interpretation of results of investigation in context of the patient Final diagnosis or additional investigations

Fever
Fever for one month Fever for one month with heart murmur Fever for one month with heart murmur and roth spot Provisional diagnosis : infective endocarditis Essential investigations : echocardiogram, hemoculture

Dyspnea
Cardiac disease Pulmonary disease Metabolic causes Psychiatric disease

Dyspnea
Acute dyspnea for one day Acute dyspnea with bilateral wheezing Acute dyspnea with bilateral wheezing and cardiomegaly and third heart sound Diagnosis : acute heart failure Investigations : ECG and chest X-ray and echocardiogram

Edema
Edema of both legs Edema of both legs and ascites Edema of both legs and ascites and normal jugular venous pressure Edema of both legs and ascites and normal jugular venous pressure with spider nevi and jaundice Diagnosis: chronic liver disease ,probable liver cirrhosis

Approach to heart failure

What is the etiology? eg. valvular disease Stage of heart failure? eg. stage A, B, C, or D Functional class? eg. NYHA FC I-IV Any precipitating factors? Prognosis?

Alteration of consciousness
Localizing signs No localizing signs Diffuse brain damage from Encephalitis Metabolic disturbance: hyponatremia hypernatremia, hypoglycemia, hyperglycemia, hypercalcemia, uremia, hepatic encephalopathy

Approach to neurologic patients

Locate the anatomic location of the disease Determine the etiology Example: acute onset of hemiparesis with global aphasia indicates the location to be at the frontal and parietal lobe of the dominant hemisphere and the etiology is most likely from vascular disease such as infarction from thrombosis or embolism

Disease assessment
Severity or staging Activity Complications or sequele Prognosis Example : CA colon, adenocarcinoma, stage 4, complication- gut obstuction, 5 year survival 5%

Definite diagnosis
Diagnostic criteria What investigation is the gold standard? Example: tissue pathology is the gold standard for the diagnosis of malignancy A perfect diagnostic test should have a sensitivity and specificity of 100%

Definition of sensitivity and specificity

Sensitivity : The fraction of those with the disease correctly identified as positive by the test. Specificity: The fraction of those without the disease correctly identified as negative by the test.

Positive and negative predictive value

Positive predictive value (+ PV) is the fraction of people with positive tests who actually have the condition. Negative predictive value (-PV) is The fraction of people with negative tests who actually don't have the condition.

The sensitivity and specificity are properties of the test. The positive and negative predictive values are properties of both the test and the population you test. If you use a test in two populations with different disease prevalence, the predictive values will be different. A screening test is most useful if directed to a high-risk population (high prevalence and high predictive value).

Calculation of sensitivity and specificity

Patient with the disease Test is positive Patient without the disease

A
True Positive

B
False Positive

Test is negative

C
False Negative

D
True Negative

Using the 2X2 table you can calculate

Sensitivity = a / (a+c) Specificity = d / (b+d) + PV = a/(a+b) - PV = d/(c+d)

Knowing the prevalence of the disease in the population is necessary for these calculations

Understanding Predictive Value

Prevalence is defined as the number of patients per 100,000 population who have the disease at a given time. A high +PV indicates a strong chance that a person with a positive test has the disease whereas a low +PV is usually found in populations with low prevalence of the condition being examined. A high -PV means that a negative test in effect rules out the disease.

Effects of Prevalence Sensitivity=95% Specificity=95%

Populations Prevalence 0.1% 1.0% 2.0% 5.0% 50% Predictive Value of a Positive Test 1.9% 16.1% 27.9% 50% 95%

Effects of Prevalence Sensitivity=99% Specificity=99%

Populations Prevalence
0.1% 1.0% 2.0% 5.0% 50%

Predictive Value of a Positive Test

9.0% 50% 66.9% 83.9% 99%

Test interpretation

When a sign, test or symptom has an extremely high specificity (say, over 95%), a positive result tends to rule in the diagnosis. When a sign, test or symptom has a high sensitivity, a negative result rules out the diagnosis.