Reading with the purpose of answering the seven fundamental clinical questions improves retention of information and facilitates the application of “book knowledge” to “clinical knowledge.”
The clinical problem-oriented approach to reading is different from the classic “systematic” research of a disease. Patients rarely present with a clear diagnosis; hence, the student must become skilled in applying textbook information to the clinical scenario. Because reading with a purpose improves the retention of information, the student should read with the goal of answering specific questions. There are several fundamental questions that facilitate clinical thinking. These are:
1. What is the most likely diagnosis?
2. How would you confirm the diagnosis?
3. What should be your next step?
4. What is the best screening strategy in this situation?
5. What are the risk factors for this condition?
6. What are the complications associated with the disease process?
7. What is the best therapy?
Reading with the purpose of answering the seven fundamental clinical questions improves retention of information and facilitates the application of “book knowledge” to “clinical knowledge.”
The method of establishing the diagnosis was discussed in the previous section. One way of determining the most likely diagnosis is to develop standard “approaches” to common clinical problems. It is helpful to understand the most common causes of various presentations, such as “the worst headache of the patient’s life is worrisome for a subarachnoid hemorrhage” (see the Clinical Pearls at end of each case).
The clinical scenario would be something such as:
A 38-year-old woman is noted to have a 2-day history of unilateral, throbbing headache with photophobia. What is the most likely diagnosis?
With no other information to go on, the student would note that this woman has a unilateral headache with photophobia. Using the “most common cause” information, the student would make an educated guess that the patient has a migraine headache. If instead the patient is noted to have “the worst headache of her life,” the student would use the Clinical Pearl:
The worst headache of the patient’s life is worrisome for a subarachnoid hemorrhage.
The more common cause of a unilateral, throbbing headache with photophobia is a migraine, but the main concern is subarachnoid hemorrhage. If the patient describes this as “the worst headache of her life,” the concern for a subarachnoid bleed is increased.
In the scenario above, the woman with “the worst headache” is suspected of having a subarachnoid hemorrhage. This diagnosis could be confirmed by a CT scan of the head and/or lumbar puncture. The student should learn the limitations of various diagnostic tests, especially when used early in a disease process. The lumbar puncture (LP) showing xanthochromia (red blood cells) is the “gold standard” test for diagnosing subarachnoid hemorrhage, but it may be negative early in the disease course.
What should be your next step? This question is difficult because the next step has many possibilities; the answer may be to obtain more diagnostic information, stage the illness, or introduce therapy. It is often a more challenging question than “What is the most likely diagnosis?” because there may be insufficient information to make a diagnosis and the next step may be to pursue more diagnostic information. Another possibility is that there is enough information for a probable diagnosis, and the next step is to stage the disease. Finally, the most appropriate answer may be to treat. Hence, from clinical data, a judgment needs to be rendered regarding how far along one is on the road of:
1. Make the diagnosis → 2. Stage the disease → 3. Treat based on stage → 4. Follow response
Frequently, the student is taught “to regurgitate” the same information that someone has written about a particular disease, but is not skilled at identifying the next step. This talent is learned optimally at the bedside, in a supportive environment, with freedom to make educated guesses, and with constructive feedback. A sample scenario might describe a student’s thought process as follows:
1. Make the diagnosis: “Based on the information I have, I believe that the patient has a small bowel obstruction from adhesive disease because he presents with nausea and vomiting, abdominal distension, and high-pitched hyperactive bowel sounds, and has dilated loops of small bowel on x-ray.”
2. Stage the disease: “I don’t believe that this is severe disease as he does not have fever, evidence of sepsis, intractable pain, peritoneal signs, or leukocytosis.”
3. Treat based on stage: “Therefore, my next step is to treat with nothing per mouth, nasogastric (NG) tube drainage, IV fluids, and observation.”
4. Follow response: “I want to follow the treatment by assessing his pain (I will ask him to rate the pain on a scale of 1 to 10 every day), his bowel function (I will ask whether he has had nausea, vomiting, or passed flatus), his temperature, abdominal examination, serum bicarbonate (for metabolic acidemia), white blood cell count, and then reassess him in 48 hours.”
In a similar patient, when the clinical presentation is unclear, perhaps the best “next step” may be diagnostic such as an oral contrast radiologic study to assess for bowel obstruction.
Usually, the vague query, “What is your next step?” is the most difficult question because the answer may be diagnostic, staging, or therapeutic.
A major role of the family physician is screening for common and/or dangerous conditions where there may be interventions to alleviate disease. Cost-effectiveness, ease of the screening modality, wide availability, and presence of intervention are some of the important issues. The age, gender, and risk factors for the disease process in question play roles. In general, age is one of the most important risk factors for cancer. For instance, with breast cancer, an annual mammography is recommended in women older than age 50 years. This imaging technique is widely available, inexpensive, safe, decreases mortality, and is cost-effective.
Understanding the risk factors helps the practitioner to establish a diagnosis and to determine how to interpret tests. For example, understanding risk-factor analysis may help in the management of a 55-year-old woman with anemia. If the patient has risk factors for endometrial cancer (such as diabetes, hypertension, anovulation) and complains of postmenopausal bleeding, she likely has endometrial carcinoma and should have an endometrial biopsy. Otherwise, occult colonic bleeding is a common etiology. If she takes NSAIDs or aspirin, then peptic ulcer disease is the most likely cause.
Clinicians must be cognizant of the complications of a disease, so that they will understand how to follow and monitor the patient. Sometimes the student has to make the diagnosis from clinical clues and then apply his/her knowledge of the consequences of the pathologic process. For example, “A 26-year-old male complains of right lower-extremity swelling and pain after a trans-Atlantic flight” and his Doppler ultrasound reveals a deep vein thrombosis. Complications of this process include pulmonary embolism (PE). Understanding the types of consequences also helps the clinician to be aware of the dangers to a patient. If the patient has any symptoms consistent with a PE, a ventilation-perfusion scan or CT scan with angiographic imaging of the chest may be necessary.
To answer this question, not only does the clinician need to reach the correct diagnosis and assess the severity of the condition, but (s)he must also weigh the situation to determine the appropriate intervention. For the student, knowing exact dosages is not as important as understanding the best medication, route of delivery, mechanism of action, and possible complications. It is important for the student to be able to verbalize the diagnosis and the rationale for the therapy.
Therapy should be logical and based on the severity of disease and the specific diagnosis. An exception to this rule is in an emergent situation, such as respiratory failure or shock, when the patient needs treatment even as the etiology is being investigated.
1. There is no replacement for a meticulous history and physical examination.
2. There are four steps in the clinical approach to the family medicine patient: making the diagnosis, assessing severity, treating based on severity, and following response.
3. There are seven questions that help to bridge the gap between the textbook and the clinical arena.
Taylor RB, David AK, Fields SA, Phillips DM, Scherger JE. Family Medicine: Principle and Practice. 7th ed. New York, NY: Springer-Verlag; 2007.