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:Diagnostic Thinking Weight gain + edema Exertional dyspnea but clear lungs Pallor High BP + history of HTN Tachycardia S4 gallop Risk factors for CAD Ex-smoker Edema cause? Heart Liver Kidneys Nutrition Dyspnea Heart Lungs Anemia Restriction Deconditioning Tachycardia 4
Slide notes:This lecture will discuss how clinicians arrive at a specific diagnosis to guide treatment. The previous lecture concluded with the problem list depicted on this slide, derived from an analysis of information gathered about a man with swelling in his ankles. On the right are the beginnings of the differential diagnosis. Consider first the weight gain and edema [ ih - dee - muh ], which the man reported in his history. Edema could be caused by several conditions of different organ systems. Edema may result from heart disease, for example, caused by long-standing high blood pressure. It may also result from liver disease, such as cirrhosis [ si - roh -sis] due to chronic alcoholism. It could also be a case of kidney disease, such as nephrotic [ nuh- frot -ik ] syndrome. In some countries, edema such as this might be the result of severe malnutrition, although this form is rare in the United States. The slide also includes the differential diagnosis for shortness of breath, or dyspnea [ disp -nee-uh] . This condition may result from diseases of many organ systems, such as heart disease, lung disease, anemia or low blood count, physical restriction due to a large abdomen in obese patients, or deconditioning due to inactivity. Some medical conditions or categories of conditions exist on both lists; for example, hypertension could cause both edema and dyspnea, and these may be clues to whats wrong with this man. These data allow the clinician to guess about the condition in question, but this kind of reasoning goes only so far in reaching an accurate diagnosis. To think about the problem in a more structured way, some rules and procedures are needed. 4