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.)