CLINICAL DECISION MAKING 26 nov 2022.pptx

Clinical decision making is a balancing act – of art and science, intuition and analysis, gut instinct and evidence, experience and knowledge

It is important to hear the patient and enable them to build knowledge to support their self-care and self-management strategies

Patients, clients and their families expect to be given information on their condition and treatment options with the practitioner and broader clinical team taking their individual preferences into account

1. CLINICAL DECISION MAKING

2. What is Clinical Decision Making? Decision making is a complex process that involves not only interpersonal aspects but influences from recognized and unrecognized outside sources We are all involved in decisions in life from the simple to the complex, those that deal with patients and clients to those that deal with our life outside work Decision making can range from fast, intuitive, or heuristic decisions through to well reasoned, analytical, evidence-based decisions that drive patient and client care

3. Task : Simple Complex Uncertainty : Low Decision making : intuitive, heuristic Volume : High High Analytical & evidence-based Low S pectrum of decision making Clinical decision making is a balance of experience, awareness, knowledge and information gathering, using appropriate assessment tools, colleagues and evidence-based practice

4. The Core Skills of Clinical Decision Making Good, effective clinical decision making requires a combination of experience and skills Pattern recognition : learning from experience Critical Thinking : removing emotion from our reasoning being ' sceptical ', with the ability to clarify goals ex amine assumptions be open-minded recognize personal attitudes and bias able to evaluate evidence Communication Skills: active listening - the ability to listen to the patient, what they say - what they don't say, their story, their experiences and their wishes thus enabling a patient- centred approach that embraces self-management information provision - the ability to provide information in a comprehensible way to allow patients and family to be involved in the decision making process

5. The Core Skills of Clinical Decision Making Good, effective clinical decision making requires a combination of experience and skills Evidence-based approaches: Using available evidence and best practice guidelines as part of the decision making process T eam work : Using the gathered evidence to enlist help, support and advice from colleagues and the wider multi-disciplinary team It's important to liaise with colleagues, listen and be respectful, whilst also being persistent when you need support so that you can plan as a team when necessary Sh aring : learning and getting feedback from colleagues on your decision making R eflection: U sing feedback from others, and the outcomes of the decisions to reflect on the decisions that were taken in order to enhance practice delivery in the future It's also important to reflect on whole decision making strategies to ensure that you hone your decision making skills and learn from experience.

6. Factors that affect decision making D ecisions would be made objectively , with a full set of evidence , an endless bank of resources, no time pressures, minimal interruptions , decision support tools to hand and plenty of energy to handle any decision making situation at any time of the day Informed clinical decision making should include a variety of information and knowledge sources. Knowing the evidence Knowing yourself Knowing the Patient and Person Knowing the Environment

7. The Decision Making Process Clinical decision making will typically follow a process moving from gathering the necessary information through to the final decision and outcome Using cues and gathering and analysing patient data systematically Making judgements Making decisions Evaluating Outcomes

8. The steps in clinical decision making

9. Pattern recognition and analytic reasoning in the development of a clinical diagnosis

10. Clinical decision making in the diagnosis and therapy of a disease.

11. Clinical Reasoning -the Need Student requests Observation of records and presentations Medical error Medical Legal

12. Clinical Reasoning-Definition Defines the thinking process, whereby a physician gathers appropriate data for a clinical problem; arrives at a diagnosis; identifies a ‘treatment of choice’ and gives a reasoned recommendation to the patient

13. Clinical Reasoning Process THE FUNDAMENTAL SKILL OF CLINICAL PROBLEM SOLVING Data gathering Diagnostic reasoning Therapeutic reasoning Recommendation

14. Records An essential learning tool Good medical practice Medical legal requirements

15. Records Data gathering Clinical reasoning Records

16. Data Gathering History Onset Sequence Presentation Physical exam General Specific Focussed

17. Diagnostic Reasoning Anatomic/Physiologic Dx Differential Dx Clinical Dx Investigation Provisional (working) Dx

18. Differential Diagnosis Congenital Traumatic Infectious Neoplastic Vascular Metabolic Degenerative Psychogenic

19. Therapeutic Reasoning Natural History Treatment options Expectations Risks Treatment of Choice

20. Recommendation

21. Example-1 Mrs Clarke, a 48 yrs old female presents to her family physician, having been wakened by a bad headache. When in the bathroom, she was aware of double vision and noticed in the mirror that her left eyelid was drooped and the left pupil large.

22. She became mildly nauseated and went to her doctors office where her examination shows a L dilated unresponsive pupil and absent medial,upward and downward gaze. There are no other complaints or findings.

23. Diagnostic Reasoning What is your anatomical/physiological diagnosis?

24. What is your anatomical diagnosis ? III palsy retro-orbital cavernous sinus subarachnoid space

25. Diagnostic Reasoning What is your clinical / differential diagnosis?

26. What is your Clinical / Differential diagnosis? Vascular Post communicating aneurysm Cavernous aneurysm Vascular III palsy Neoplastic Meningioma pituitary tumor epidermoid craniopharyngioma Traumatic Infectious Metabolic ? diabetic

27. Investigations What confirmatory investigations will you request?

28. What confirmatory investigation will you request? Imaging CT Scan MRI Angiograms Laboratory routine electrolytes endocrine CSF specific

29. Investigations Ct scan – sellar mass MRI – sellar mass Visual fields – normal Angiograms Laboratory Prolactin - 6000

30. Diagnostic Reasoning What is your Provisional Diagnosis?

31. Provisional Dx Pituitary tumour ? Non-functioning ? Prolactin secreting Apoplexy

32. Therapeutic Reasoning Natural History Management considerations Endocrine Tumour Mass Vision

33. Therapeutic Reasoning Endocrine Acute Replacement Expectations Risks

34. Therapeutic Reasoning Tumor Medical Surgical X-RT Expectations Risks

35. Treatment of Choice

36. Recommendation Bromocryptine Hormone Replacements

37. Example-2 A 68-years-old female - Sheila Tanopyh , presented to the local hospital four days ago with severe headaches, nausea and vomiting. A diagnosis of flu was made. She was admitted, given 3 L. intravenous fluids daily and analgesics for her headache.

38. On Day 4, she became confused, drowsy and then today she had a major seizure without focal features. She was transferred.

39. On arrival her vital signs are unremarkable. BP 140/80. Pulse 80. Temperature 37.8. She has moderate neck stiffness. Her ABC ’ s on O 2 nasal prong and C-spine are unremarkable.

40. Her neurological examination is as follows: LeOC - E 2 M 4 V 3 = 9/15 RR - 18 Pupils - 3 mm E + R EOM - normal Lateralization - nil

41. Diagnostic Reasoning What is her anatomic / physiologic diagnosis? What is the differential / clinical diagnosis?

42. What more information do you want?

43. Investigations

44. CT scan Mild subarachnoid blood Laboratory: Hemoglobin 128 WBC 8.4 INR 1.02 All remaining blood work is normal except: Electrolytes Na 114 Cl 90 K 3.6 HCO 3 22

45. Diagnostic Reasoning What is your provisional diagnosis?

46. Hyponatremia Water Excess Saline depletion

47. Therapeutic Reasoning What is the natural history?

48. Management Strategies What are the options Expectations Risks

49. Recommendation Treatment of Choice

50. Summary Clinical decision making is a balancing act – of art and science, intuition and analysis, gut instinct and evidence, experience and knowledge It is important to hear the patient and enable them to build knowledge to support their self-care and self-management strategies Patients, clients and their families expect to be given information on their condition and treatment options with the practitioner and broader clinical team taking their individual preferences into account