Institute:Office of National Coordinator (ONC) Workforce Training Curriculum
Component:The Culture of Health Care
Unit:Health Care Processes and Decision Making
Lecture:Gathering data and analyzing findings
Making a diagnosis
The impact of EHRs and technology on clinical decision-making
Slide content:Man with Edema Clinical Data Hierarchy Observations Global complex None so far Diseases Hypertension ? Alcohol? Ischemic heart disease ? Toxin ? Syndromes Heart failure ? Anemia ? Facets Weight gain + edema ; 225/140 + S4; pallor; tachycardia Findings Weight gain, DOE, Hx HTN, former smoker , pallor, clear lungs, S4, normal abdomen, edema Observations HPI progressive wt gain; shoes, then pants, fit tight; exertional dyspnea; allergy: aspirin (rash); HTN Rx ( slowed me down); PMH ? HTN on ? Tx SOC quit smoking; SURG tonsillectomy GEN pale; healthy M VS 225/140 120 12 LUNGS clear HEART S4; no M ABD nontender; no HSM EXT 2 + pitting to mid-shin Empirium Clinic environment, staff, distance to parking lot 4.7 Table: Depiction of how the hierarchy for clinical data might work for man with edema, or swelling, of the ankles 14
Slide notes:This slide depicts how this hierarchy might work for the man who had swelling in his ankles. Starting at the empirium are all the observations the clinician might have made, which are too numerous to mention here. In the second level from the bottom are the observations, including the mans history of weight gain, the tight-fitting pants, his high blood pressure, and so forth. The clinician often uses a specialized shorthand to note observations, usually to save time. For example, HTN [H-T-N] is hypertension, VS [V-S] stands for vital signs, and EXT [E-X-T] refers to extremities. Moving up another level, the findings include a subset of those observations that seem to be key to understanding his problem, specifically his weight gain, shortness of breath when he exerts himself (dyspnea [ disp -nee-uh] on exertion, or D-O-E), and history of high blood pressure. The category of facets allows a grouping of some of the findings. For example, his weight gain seems to go together with edema [ ih - dee - muh ], as shown with his fluid retention. The high blood pressure goes together with an abnormal heart sound, called an S4, which occurs in patients with hypertension. His pale skin might be connected with his rapid pulse, but its dangerous to decide that two things are connected when they might not be, so those findings are left separate for now. Next, the clinician can try to group these findings and facets into syndromes. For example, pale skin suggests that the man might be anemic, so he may need a complete blood count to test for anemia. His history of high blood pressure, weight gain, shortness of breath on exertion, and swelling in his ankles all suggest that he may have the syndrome of heart failure. The next level is to consider diseases. If the patient has heart failure, it could be due to high blood pressure, alcoholism, coronary artery disease, or perhaps the ingestion of some toxin. This leads to what clinicians call the differential diagnosis . At this stage, the clinician has begun to make sense of the symptoms and signs, reducing the data by organizing it into meaningful groupings. Now the clinician can begin treatment and diagnostic testing. 14