# USMLE Step 1 Review/Clinical decision-making

Clinical decision-making is a broad subject area covering biostatistics and epidemiology. Also covered are an approach to the patient interview, the physical examination, and the establishment of a differential diagnosis.

## Patient interview

The patient interview, or patient history, consists of:
* chief complaint (CC)
* history of present illness (HPI)
* medications
* allergies
* past medical history (PMH)
* past surgical history (PSH)
* social history
* family history
* review of systems (ROS)
Eliciting the HPI and exploring symptoms is done systematically:
* Onset of pain (what was the patient doing when the pain started?)
* Palliative or Provocative factors for the pain
* Quality of pain (burning, stabbing, aching, etc.)
* Radiation (up to jaw, down left arm, etc.)
* Severity of pain (usually 1 - 10 scale)
* Timing of pain (eg: after meals, in the morning, how long it lasts, etc.)
Similarly:
* Site of pain
* Onset of pain
* Character of pain (dull, sharp, aching, stabbing, tearing etc.)
* Radiation of pain (eg. central abdominal pain radiating to Right Iliac Fossa)
* Associated factors (eg. nausea/vomiting)
* Timing of pain/duration
* Exacerbating/alleviating factors
* Severity of pain (usually 1 - 10 scale)
Alternatively:
* Aggravatiing and Alleviating factors
* Severity
* Character, quality
* Location
* Associated symptoms
* Setting
* Timing
(ASCLAST means let the patient talk first, then ask him/her specific questions.)
to make a differential diagnosis for a problem use the word VINDICATE V vascular I inflamation / Infection N Neoplasm D Degenerative I Intoxication C collagen disease / congenital disease A autoimmune disease T Trauma E endocrine

## Differential diagnosis

The patient interview rarely indicates a single diagnosis; rather, usually there is a list of potential diagnoses, called a differential diagnosis. Systematically thinking through a differential diagnosis ensures that all possibilities are considered. The mnemonic VITAMIN C is commonly used to accomplish this:
* Vascular
* Infectious
* Traumatic
* Autoimmune
* Metabolic
* Idiopathic/iatrogenic
* Neoplastic
* Congenital

## Admission orders

When admitting a patient to the hospital, several orders must be written. The DAVE WILMINGTON mnemonic helps to accomplish this systematically:
* Diet
* Activity
* Vital signs (how often)
* Excrement (test urine / stool)
* Weight (how often to monitor)
* Input/output (eg, "strict ins/outs")
* Labs (what, how often)
* Meds (which, route, interval)
* I V fluids (what and at what rate)
* Nursing care (e.g. position, wound care, up in chair, ostomy care etc)
* General care (e.g. Physical Therapy, Respiratory Therapy etc)
* Tests (X-ray, EKG, EEG etc)
* Observe for reaction, seizure, neuro exams
* Notify parameters (e.g. Temp > 100 / respiration changes)
The ADC VAAN DIML mnemonic is also used commonly:
* Admit (23 hours, full admit, service of attending,...)
* Diagnosis
* Condition ("Stable", "Guarded", etc.)
* Vitals (post-op, routine, q 1 hour, etc.)
* Allergies
* Activities (Strict bed rest, fall precautions, ad lib, bathroom privileges, etc.)
* Nursing (Strict I&O's, Daily weights, Call P.R.N. whatever, etc.)
* Diet (NPO, Regular, Clears - advance diet as tolerated, 2000 cal ADA, renal, etc.)
* IV fluids (D5 1/2 NS c 20 KCL at 110 ml/hr, LR @ 100 ml/hr, etc.)
* Meds (scheduled and PRN's)
* Labs and x-ray (CBC in AM, PCXR in PACU, etc.)