Clinical thinking and decision making in practice. An elderly patient with vertigo and high sedimentation rate

A 77-year-old woman was admitted because of progressive vertigo, nausea and a dysarthric speech disorder. The patient's history of diabetes mellitus, hypertension and hypercholesterolaemia, and the finding of murmurs over peripheral arteries at physical examination led to a presumptive diagnosis of cerebellar ischaemia in the context of generalized atherosclerosis. However, the diagnosis was revised when bilateral cerebellar infarction was demonstrated radiologically, and a biopsy of a temporal artery revealed giant cell arteritis. Despite treatment with prednisone (60 mg daily) the patient's neurological condition deteriorated, and she succumbed several months later to pneumonia. The case illustrates the pitfalls in the diagnostic approach of elderly patients with multiple pathology and it also emphasizes that in an elderly person with high erythrocyte sedimentation rate (> 100 mm in the first hour) temporal arteritis should be ruled out as soon as possible to prevent further neurological damage.     

Clinical thinking and decision making in practice. A patient with icterus

A 55-year-old man was admitted because of cholestatic jaundice. Extrahepatic obstruction and viral causes were excluded. A diagnosis of liver damage due to the combination preparation amoxicillin and clavulanic acid (Augmentin) was made. The patient had an uneventful recovery. It is pointed out that in case of cholestatic jaundice drug-induced cholestasis should be suspected early in the course. History taking is an important tool. If a suspected drug is found other causes of the disease can be excluded with simple tests.     

Clinical thinking and decision making in practice. A patient with persistent fever

A 20-year old man was admitted to hospital with fever and malaise after travel to India. He was soon found to have typhoid fever, caused by a multi-drug resistant Salmonella typhi. According to in-vitro resistance testing he was treated with cefotaxim, but fever and shivering were still present after 7 days of cefotaxim, with liver enzyme disturbances. The physicians caring for him started an extensive search for possible complications of typhoid fever, and they thought of the possibility of an alternative disease to explain the fever. When cefotaxim was stopped all symptoms and signs disappeared. During every medication, drug fever is a possibility. This diagnosis can only be supported by discontinuing the use and if necessary, restarting it (dechallenge and rechallenge).     

Clinical thinking and decision making in practice. A patient with anal cancer and hypercalcemia

A 57-year-old male patient, recently known with an anal carcinoma with inguinal lymph node involvement, was admitted because of anorexia, nausea, vomiting and constipation. On physical examination the patient was dehydrated, and a systolic murmur, grade III/VI, punctum maximum apex cordis, was heard. Serum calcium was raised (4.50 mmol/l), as was the serum creatinine (328 mumol/l). Both values had been normal 14 days before admission. Serum parathormone was suppressed. A bone scan did not reveal evident lesions in the skeleton. FDG-PET scan showed uptake of the tracer into the bone marrow. A bone biopsy showed metastasis of a squamous cell carcinoma. Shortly after that the patient died. Hypercalcaemia is associated with cancer. Colorectal/anal carcinomas have a low incidence of hypercalcaemia. The prognosis of patients with cancer associated with hypercalcaemia is poor.     

Feasibility and effects of decision aids.

Decision aids for patients have recently been introduced in health care. A literature review was conducted to address the following research questions: 1) which types of decision aids have been developed?; 2) to what extent are they feasible, and acceptable to patients and health care providers?; 3) do decision aids affect the decision-making process and patients' outcomes? Thirty non-controlled (e.g., one-group-only designs) and controlled studies (e.g., randomized experimental designs) were identified. Decision aids were found to be feasible and acceptable to patients and to increase the agreement between patients' values and decisions and patients' knowledge. The effects of decision aids on decisions and on patients' outcomes, including decision uncertainty, satisfaction, and health, have rarely been addressed. When studied, the beneficial effects of decision aids on these outcomes appear to be rather modest. Implications for future development of decision aids and the design of studies are discussed.     

Do patient decision aids meet effectiveness criteria of the international patient decision aid standards collaboration? A systematic review and meta-analysis.

OBJECTIVE: To describe the extent to which patient decision aids (PtDAs) meet effectiveness standards of the International Patient Decision Aids Collaboration (IPDAS). DATA SOURCES: Five electronic databases (to July 2006) and personal contacts (to December 2006). RESULTS: Among 55 randomized controlled trials, 38 (69%) used at least 1 measure that mapped onto an IPDAS effectiveness criterion. Measures of decision quality were knowledge scores (27 trials), accurate risk perceptions (12 trials), and value congruence with the chosen option (3 trials). PtDAs improved knowledge scores relative to usual care (weighted mean difference [WMD] = 15.2%, 95% confidence interval [CI] = 11.7 to 18.7); detailed PtDAs were somewhat more effective than simpler PtDAs (WMD = 4.6%, 95% CI = 3.0 to 6.2). PtDAs with probabilities improved accurate risk perceptions relative to those without probabilities (relative risk = 1.6, 95% CI = 1.4 to 1.9). Relative to simpler PtDAs, detailed PtDAs improved value congruence with the chosen option. Only 2 of 6 IPDAS decision process criteria were measured: feeling informed (15 trials) and feeling clear about values (13 trials). PtDAs improved these process measures relative to usual care (feeling uninformed WMD = -8.4, 95% CI = -11.9 to -4.8; unclear values WMD = -6.3, 95% CI = -10.0 to -2.7). There was no difference in process measures when detailed and simple PtDAs were compared. CONCLUSIONS: PtDAs improve decision quality and the decision process's measures of feeling informed and clear about values; however, the size of the effect varies across studies. Several IPDAS decision process measures have not been used. Future trials need to use a minimum data set of IPDAS evaluation measures. The degree of detail PtDAs require for positive effects on IPDAS criteria should be explored.     

Toward the 'tipping point': decision aids and informed patient choice

Preference-sensitive treatment decisions involve making value trade-offs between benefits and harms that should depend on informed patient choice. There is strong evidence that patient decision aids not only improve decision quality but also prevent the overuse of options that informed patients do not value. This paper discusses progress in implementing decision aids and the policy prospects for reaching a "tipping point" in the adoption of "informed patient choice" as a standard of practice.     

Clinical thinking and decision making in daily practice. An elderly man with hyponatremia

An 88-year-old man presented with nausea and vomiting. Recently a cutaneous B-cell lymphoma had been diagnosed on his right cheek. Laboratory investigation showed hyponatraemia. Fluid restriction was started, based on the diagnosis of the syndrome of inappropriate antidiuretic hormone secretion (SIADH). However the hyponatraemia persisted and a diagnosis of 'reset osmostat' was made. CT of the abdomen revealed slight bilateral adrenal enlargement, which was interpreted as adrenal incidentaloma. No other localisation of the lymphoma, besides that on the right cheek, was seen. Although the symptoms initially disappeared, they recurred and were quickly followed by hypotension. The patient died. Post-mortem examination showed bilateral destruction of the adrenal glands due to lymphoma. The correct diagnosis was Addison's disease. This case shows that diseases do not always present with all the classical symptoms, and that it is important to consider test characteristics of diagnostic tests and to judge investigations in the context of the other clinical findings.     

Clinical thinking and decision making in practice. A patient with pain in the upper abdomen

A 74-year-old woman was admitted because of abdominal pain. A few weeks before this admission she had had a cerebral infarction in the right hemisphere, reflected by a left sided paralysis, dysarthria, depression and a slight cognitive disorder. The night before admission she woke up from a sharp, continuous pain in the right upper abdomen. Physical examination disclosed pain in the right upper abdomen on palpation. Laboratory tests showed a slight elevation of all 'liver' enzymes. A differential diagnosis of cholecystitis or pyelonephritis was made. Additional tests did not confirm either of these diagnoses. Because of immobilisation pulmonary embolism was then suspected. This diagnosis was confirmed by scintigraphy. The patient was treated and made a full recovery. Diagnostic errors can be made by faulty triggering and omitting verification. The diagnostic strategy for pulmonary embolism is a ventilation perfusion scan, which is followed in case of a non high-probability result by pulmonary angiography. It is emphasized that the presentation of pulmonary embolism can be aspecific.     

Clinical judgment and clinical practice guidelines

Clinicians make judgments under conditions of uncertainty. Decision research has shown that in uncertain situations individuals do not always act rationally, coherently, or to maximize their expected utility. Advocates of clinical guidelines believe that these guidelines will eliminate some of the cognitive biases that the practitioner may introduce into the medical decision-making process in an attempt to reduce its uncertainty. Other physicians have grave doubts about guidelines' application in practice. Guideline implementation lags well behind their development. Studies of practicing physicians and a survey of clinicians in one specialty and setting indicate that experienced clinicians may be implementing guidelines selectively. Many clinicians are concerned that guidelines are based on randomized trials and do not reflect the complexity of the real world, in which a decision's context and framework are important. Their reluctance also may be due to the difficulty of applying general guidelines to specific clinical situations. The problem will only increase in the future. The patients of the 21st century will be older and have more complex disease states. Physicians will have more patient-specific therapies and need to exercise more sophisticated clinical judgment. They may be more willing to use guidelines in making those judgments if research can demonstrate guidelines' effectiveness in improving decision making for individual patients.     

Clinical practice guidelines and primary care. SESPAS report 2012

Clinical practice guidelines are intended to serve as a bridge between the decision levels and the sources of knowledge, giving decision makers the best synthesis of scientific evidence and an analysis of context, to provide elements of judgement and to transfer scientific knowledge into clinical practice. However, the actual impact on health care is variable and effectiveness in changing medical practice, moderate. Qualitative and quantitative studies show that most primary care physicians consider that the guides are a valuable source of advice and training and a kind of improving the quality of healthcare. However, they underline its rigidity, the difficulty to apply to individual patients and that their main goal is to reduce healthcare costs. In Spain, there are several experiences as GuíaSalud in developing clinical practice guidelines aimed specifically at primary care. However, the proper implementation of a clinical practice guideline includes not only the quality and thoroughness of the evidence, but the credibility of professionals and organizations and other contextual factors such as characteristics of patients, providers and organizations or systems. An important step in future research is to develop a better theoretical understanding of organizational change that is required for management and professionals to give appropriate guidance to the implementation of the clinical practice guidelines.     

The inclusion of patient testimonials in decision aids: effects on treatment choices.

BACKGROUND: Decision aids often provide statistical information and patient testimonials to guide treatment choices. This raises the possibility that the testimonials will overwhelm the statistical information. METHODS: Prospective jurors in Philadelphia County were presented with hypothetical statistical information about the percentage of angina patients who benefit from angioplasty and bypass surgery (50% and 75%, respectively). They were also given written testimonials from hypothetical patients who had benefited or not benefited from each of the two treatments. The numbers of patients benefiting and not benefiting were varied to be either proportionate to the statistical information or disproportionate. In study 1, all participants received 1 testimonial from a patient who had benefited from angioplasty and 1 from a patient who had not. Participants receiving the proportionate questionnaire version were also given 3 testimonials from patients who benefited from bypass surgery and 1 from a patient who did not, coinciding with the hypothetical statistical information. In contrast, participants receiving the disproportionate questionnaire version received only 1 testimonial from a patient who benefited from surgery and 1 from a patient who did not. In study 2, all participants received 2 examples of patients who benefited from angioplasty and 2 who did not. Participants with the proportionate questionnaire version received the same testimonials regarding surgery as in study 1. Those receiving the disproportionate questionnaire version received 2 testimonials from patients who benefited from bypass and 2 from patients who did not. Finally, a separate set of participants in study 2 received a questionnaire with no testimonials. RESULTS: In study 1, 30% of participants receiving the disproportionate questionnaire version chose bypass surgery versus 44% of those receiving the proportionate questionnaire (P = 0.002 by chi2). In study 2, 34% of participants receiving the disproportionate questionnaire version chose bypass surgery versus 37% of those receiving the proportionate questionnaire (P = 0.59 by chi2). Of those receiving no patient testimonials, 58% chose bypass surgery. CONCLUSIONS: The inclusion of written patient testimonials significantly influenced hypothetical treatment choices. Efforts to make the mix of positive versus negative testimonials proportionate to statistical information may, under some circumstances, affect choices in ways that cannot automatically be assumed to be optimal.