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Introduction TO Advanced Diagnostics
Shadow Health
University
University of Memphis
Academic year: 2019/2020
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INTRODUCTION TO ADVANCED DIAGNOSTICS
Role: Advanced Practice Provider
Patient’s name: Mr. Bailey
Patient presented with cold symptoms and fever
Differentials = diseases
Diagnostic Process
Expectations:
demonstrate a working knowledge of diagnoses and diagnostic tests
consider cultural and social components of the cases while making diagnostic
decisions since they can have a direct impact on the patient’s quality of life
Frameworks:
Hypothetico-deductive method of decision making
As much information is gathered from the patient as possible and then a
list of differential diagnoses is made
Then clinician adjusts their hypothesis according to new information as it
is uncovered
This is a slower, more deliberate method of diagnosing that allows for
more accurate and data-driven decisions
It narrows the possibility for error but may be less suitable in an acute
care setting where important decisions must be made quickly and
decisively
Pattern Recognition
Happens automatically when a clinician is presented with a case
Clinician compares resenting case with store patterns in their memory
With any previous experiences that match the current one, they are able
to make a fast-paced decision on what the most likely diagnosis is
More prone to biases and errors
Useful when utilized by expert clinicians to make efficient decisions about
cases without abnormal factors or in an acute care setting where time is
limited
Expert clinicians do not rely solely on pattern recognition, and generally
supplement it with another decision-making framework
Steps of the diagnostic process (following these steps in a consistent and logical manner
can help avoid shortcuts and leaps in logic that leads to clinical bias)
1. Information gathering
o Clinician seek to identify all signs and symptoms through an interview and
assessment
o Signs: specific physical findings discovered in an examination
o Symptoms: subjective effects reported by the patient
o Make sure that you have as full and complete a picture of the patient’s
health as possible
o It is important to take into account their medical and social history, their
current signs and symptoms, and the results of any tests and evaluations
2. Forming a list of high-priority differentials (List differential diagnoses)
a. List is composed of all possible diagnoses that could be causing the
patient’s signs and symptoms
b. Identify any diagnoses that could threaten patient safety
c. These important diagnoses will be referred to as “Do-Not-Miss” diagnoses
d. Correctly identifying Do-Not-Miss diagnoses is a scored component of this
assignment
3. Clinician decides what diagnostic tests they would like to order
a. to gather additional information that can help them better rule in or out
certain diagnoses
b. Diagnostic tests must also be justified by linking to the signs and
symptoms that they are investigating
c. Tests are linked and ordered
4. Tests are performed and the results are interpreted
a. Results of the diagnostic testing may warrant a re-evaluation of the
gathered information
b. May include: additional testing, physical exam, or patient questions
c. If additional information is needed, clinician should circle back to an
earlier step in the process
d. If there is enough certainty from the information gathered, a final
diagnosis can be made
Steps of a differential diagnosis can help:
A methodical approach to ruling out and ruling in possible differentials can also
help to prevent a false diagnosis
Patient Assessment
Name: Tanner Bailey
Age: 30
DOB: 08/18/
Sex: Transgender male (female-to-male)
Ethnicity: White
Weight: 60 kg
Height: 165 cm
Last Vitals
BP: 119/
O2 Sat: 95%
HR: 104
RR: 22
Temp: 39
Home Meds
Injectable testosterone enanthate 100 mg/week (Brand: Delatestryl)
Denies adverse effects from testosterone injection
Allergies
Denies general allergies
Denies environmental allergies
Denies food allergies
Denies latex allergies
Provider Notes
Subjective
CC: Reports “hacking up a lung for two days”
HPI: Mr. Bailey is a 30yo transgender female to male, self-identified male, presents today with
a persistent cough for the past 2 days. States he began to feel fatigued at work approximately 3
days ago with associated runny nose and sore throat. Describes his throat as “really scratchy
and hot feeling.” Has had a loss of appetite, but feels this is due to the cough. Denies any
difficulty swallowing. States he tried to “power through” but the next day, he developed a fever
and body aches. Reports coughing and swallowing increase discomfort. He did try gargling with
warm salt water for his throat pain, but does not think it has helped much. Has not tried any otc
medications for his symptoms. His cough is frequent, intermittent and non-productive. He does
rate his throat pain at a 2/10 normally, and 4/10 while coughing or swallowing. Has had ill
contacts at work stating “a few people at work have bee sick recently.” He does wear a chest
binder and states it does not interfere with his cough.
Allergies: NKDA, No environmental, latex or food allergies
Medications: Testosterone enanthate 100 mg IM q weekly
PMH: Transgender female to male, self-identified male
PFH: Non-contributory to current condition
Social: Occupation – works at a local LGBTQ Theatre
Tobacco: Non-smoker
Recent travel: no recent travel
Physical activity: Very active – works out at the gym at least 3-4 times/week
Sexual activity: No sexual activity in the past 30 days
Health promotion: Did not have his yearly influenza vaccination
ROS: Constitutional-Positive for fever, myalgias, and fatigue
HEENT: Positive for rhinorrhea & sore throat. Denies otalgia, photophobia, itchy eyes, or
dizziness. Denies anosmia and ageusia.
Resp: Positive for cough. Denies wheezing or dyspnea
GI: Denies nausea and vomiting
Objective
Vital Signs:
BP: 119/76 HR: 104 RR: 22 T: 103F (39) SpO2: 95% (RA) Ht: 5’5” Wt: 133lbs
General Survey: Alert and oriented, with clear speech. Ill appearing. Pale, diaphoretic
Skin: Hot, moist, pale, and intact. Turgor elastic with no tenting, negative for edema, negative
for rash
HEENT: Posterior pharynx with mild injection, tonsils+3, nasal mucosa edematous and pink
with clear drainage present, frontal and maxillary sinus nontender to palpation, bilateral TM
pearly gray with no edema or erythema. Anterior and posterior cervical lymph nodes non-
palpable. Anterior cervical lymph nodes tender with palpation
Differential Selection
COVID-19 (Do-Not-Miss): is a viral infection that can cause a dry cough, fever, fatigue, and
numerous other signs and symptoms. Illnesses can range from mild to severe. Therefore,
COVID-19 must be considered a “Do-Not-Miss” diagnosis to ensure the immediate safety of the
patient. Given the patient’s presentation, this is a high-value selection which cannot be ruled in
or ruled out using only the information currently available.
Pneumonia (Do-Not-Miss): infected and inflamed air sacs in the lungs, is a high-value
selection for this scenario, the patient details, and the receptor notes. Given the patient’s
medical history, respiratory symptoms, nausea, fever, and fatigue, pneumonia is a “Do-Not-
Miss” diagnosis that must be considered to ensure the immediate safety of the patient.
Bronchitis: Lower respiratory tract viral syndrome. It can cause a cough, runny nose, fatigue,
fever, and other symptoms associated with the patient’s condition which cannot be ruled In or
ruled out using only the information currently available. This is a high value selection given the
scenario, the patient details, and the preceptor notes.
Influenza: Viral infection that affects the respiratory system. The patient’s symptoms,
particularly those aggravating the nose, throat, and lungs, are consistent with this diagnosis,
which cannot be ruled in or ruled out using only the information currently available. Given the
scenario, the patient history, and the preceptor notes this is a high value selection.
What level of knowledge about each test will I need?
Be able to make a determination on whether or not the data from a given test will yield
important information or not
Be able to interpret test information (should it be within your scope)
Correct Tests:
COVID-19 Nasopharyngeal Qualitative PCR (negative)
More accurate testing option appropriate for Tanner’s presentation
Available exclusively at hospitals, medical offices, and departments of health
Useful in ruling in or out diagnosis of COVID-19 in a timely manner and with
appropriate levels of specificity and sensitivity
Rapid Influenza Test: (Influenza A positive) (Influenza B negative)
Diagnostic testing for any flu-like symptoms or consistencies with pneumonia
during seasonal circulation is encouraged
Especially: immunocompromised patients presenting with exacerbated chronic
health problems
Rapid influenza diagnostic test is useful in ruling in or out a diagnosis of influenza
Rapid Strep Test (Negative)
A rapid strep test is useful in ruling in or out the diagnosis of strep
Will generally have both high specificity and high sensitivity
Test Linking
o Before ordering diagnostic tests, there is one more crucial step in the diagnostic
process: Test Linking
o So that diagnostic tests will be administered safely and appropriately, each test
order must be supported by a discrete and evident reason for its selection
o Link each desired test with a differential diagnosis that it will reveal the likelihood
of
What is the Purpose of Linking tests to diagnoses?
o Diagnostic tests are linked to signs and symptoms that warrant them when they
are ordered
o Ex: Giving a patient w/ a sore throat a rapid strep test is easily justifiable, but
giving that same patient a CXY may or may not be justifiable
o Link diagnostic tests to discrete signs and symptoms that the patient exhibits in
order to justify the reasoning behind ordering it
This is 2/2 insurance reasons, as ordering unnecessary tests can lead to
extensive costs for patients and institutions alike
How do I avoid bias when linking tests?
Clinician should not consider the link b/t a test and diagnosis to be any sort of proof for
or against the diagnosis’s likelihood
Tests are linked to diagnoses in order to ensure that each test is appropriate and
applicable in the situation
A strong link b/t a test and a diagnosis does not make that diagnosis more or less likely
to be an appropriate or correct final diagnosis
Reserve judgement on the value of a test until you are able to access and interpret the
specific information that test provides
If it becomes evident that you are “looking for” a certain diagnosis when linking tests
with differentials you may be experiencing cognitive bias -> It this is the case, re-examine
the situation and consider any possibilities you may have left out before making any
diagnostic decisions
When will I get to see the results of the tests?
After linking each of your selected tests to a diagnosis, you will be provided w/ the
results of any situationally appropriate diagnostic tests
Review each test carefully, along with the subjective and objective information provided
before moving on
What does a final diagnosis represent for the patient’s care?
Final diagnosis represents the beginning of the patient’s treatment that will, ideally, lead
to positive outcomes regarding their case
By providing a patient with an accurate final diagnosis, the clinician is giving them with
the best chance to receive the appropriate care for their condition
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Introduction TO Advanced Diagnostics
Course: Adv Pathophysiology (NURS 7103)
University: University of Memphis
Was this document helpful?
INTRODUCTION TO ADVANCED DIAGNOSTICS
Role: Advanced Practice Provider
Patient’s name: Mr. Bailey
Patient presented with cold symptoms and fever
Differentials = diseases
Diagnostic Process
Expectations:
demonstrate a working knowledge of diagnoses and diagnostic tests
consider cultural and social components of the cases while making diagnostic
decisions since they can have a direct impact on the patient’s quality of life
Frameworks:
Hypothetico-deductive method of decision making
As much information is gathered from the patient as possible and then a
list of differential diagnoses is made
Then clinician adjusts their hypothesis according to new information as it
is uncovered
This is a slower, more deliberate method of diagnosing that allows for
more accurate and data-driven decisions
It narrows the possibility for error but may be less suitable in an acute
care setting where important decisions must be made quickly and
decisively
Pattern Recognition
Happens automatically when a clinician is presented with a case
Clinician compares resenting case with store patterns in their memory
With any previous experiences that match the current one, they are able
to make a fast-paced decision on what the most likely diagnosis is
More prone to biases and errors
Useful when utilized by expert clinicians to make efficient decisions about
cases without abnormal factors or in an acute care setting where time is
limited
Expert clinicians do not rely solely on pattern recognition, and generally
supplement it with another decision-making framework