Topics

• History Components
• Pediatric Variations
• Geriatric Variations
• Clinical Reasoning Frameworks

NDNP 819 - Advanced Health Assessment Across Lifespan

Module: History Data, Clinical Reasoning

Clinical Reasoning Frameworks

Overview

As Advanced Practice Nurses, you will be responsible for diagnosing and managing acute and/or chronic conditions for targeted population groups. How do we develop correct diagnoses? The diagnostic process guides the construction of differential diagnoses, choosing appropriate tests, and interpreting the results. Without a clinical reasoning framework stemming from your pathophysiology, pharmacology, and history/physical exam skills, diagnoses and management will be in error contributing to poor care and patient outcomes.

There are 7 Steps in Clinical Reasoning

1. Data Acquisition
2. Accurate Problem Representation
3. Develop a Complete Framed Differential Diagnosis
4. Prioritize the Differential Diagnosis
5. Test your Hypothesis
6. Review and Reprioritize the Differential Diagnoses
7. Test the New Hypothesis

For this course we are focusing on the first 3 steps.

Steps in Clinical Reasoning

Step 1: Data Acquisition

Accurate history and physical exam data sometimes accompanied by preliminary laboratory data are key for initial diagnostic reasoning. Without it, your reasoning is faulty leading you down the wrong path.  You will need solid history taking and physical exam skills.

Step 2:  Accurate Problem Representation:

In the history, it is critical to identify the clinical problem or the chief complaint. What is bringing this patient/family in for treatment today? Using pivotal points to gather HPI data can assist in prioritizing diagnoses.
Pivotal Points are the context of the clinical problem. They are one of a pair of opposing descriptors used to compare and contrast diagnoses or clinical characteristics. They allow the APN to focus from broad differential diagnosis to more limited set of diagnosis pertinent to the patient

• Old versus new headache
• Unilateral versus bilateral edema
• Smoker versus non smoker

Step 3: Develop a Complete Framed Differential Diagnosis:

You will need to use a framework to assist you in developing differential diagnoses. It will also help you to decide additional history and physical exam information you need for your patients/families. The three frameworks are anatomic, organ/system, and pathophysiological.

Anatomic Framework: This framework helps the APN to consider the anatomical structures for possible reasons, which will lead you to ask the necessary HPI questions

CC: "I have pain in my chest".

Anatomical Structure	Possible Diagnosis	History Question
Skin	Herpes Zoster	“Do you have a rash on your chest?” “Is it painful?”
MS	Costochrondritis	“Does it hurt to touch the area?” “Does it hurt to take a deep breath or cough?”
CV	MI	“What does the pain feel like? Crushing, stabbing?”“Nausea, sweating?”
GI	GERD	“Do you have heartburn? Do you have a burning feeling in your chest?”“What have you eaten recently?”

Organ/System Framework: This framework works well for symptoms with very broad differential diagnosis

CC: " I feel fatigued"

Organ System Structure	Possible Diagnosis	History Question
Endocrine	Hypothyroidism	“Do you feel cold all the time?”
Hematologic	Anemia	“Do you have heavy menstrual cycles?”
Psychiatric	Depression	“Do you have low energy? Do you move slower than usual? How is your sleep?

Pathophysiologic Framework: For this framework, the APN thinks about possible pathological reasons for the chief complaint. One mnemonic to assist the APN is VITAMIN C: Vascular, Infectious, Traumatic, Autoimmune, Metabolic, Idiopathic/iatrogenic, Neoplastic, Congenital.

CC: " I have a headache"

Pathophysiological	Possible Diagnosis	History Question
Vascular	Temporal Arteritis	“Does the pain hurt on one side? Any blurred vision?”
Infectious	Sinusitis	“Does the pain hurt around your sinuses? Any nasal congestion or discharge?”
Neoplastic	Brain Tumor	“Do you have a history of cancer? Any problems with numbness in your face?”