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The clinical session algorithm

The clinical session algorithm

The excitement and challenge of the medical session are not to overlook especially for newly practicing physicians. Red cheeks, heart knocking, hand sweating and even head whirl may be typically experienced by many doctors even by quite experienced ones. The reason for such clinical session tension could be overestimation of the job and/ or lack of the successful scheme (algorithm) for medical management.

In this essay, I wish to emphasize that the tactful handling of medical care including clinical session is a matter of training and learning where the inherent talent influences the length of time necessary for such clinical mastering. About clinical session or examination questions regarding its duration, steps and order plus precautions and ethics are indeed worth noting. These together will shape out what is known as ‘the clinical sense’.

1- Context: what is the context of the clinical session?

By clinical session context I mean the time-place frame of the patient’s presentation. These circumstantial provisions may have influence on the clinical session as for professional progress and patient-doctor expectations. Besides care about medical perfection and contentedness the question whether a medical fee could or could not be considered can be quite sensible.

2-Patient type:  what kind of patient is this?

Broadly speaking patients may be seen as either chattering or serious. Because in some cases such definition and judgment of the patient may take time for the sake of fairness and respect to all patients, this question should be considered from the beginning and throughout the clinical session.

3- Presentation: what level of urgency does this case have?

The level of urgency may be graded in 4 levels: 1) life threatening problem, 2) potentially ailing problem, 3) naturally resolving problem and 4) intervention sparing problem.

In order to adequately define the level of urgency good knowledge and appreciation of the possible presentations (complaints) in the different diseases is required. For example, headache can be a symptom of different diseases like stress, constipation, muscle inflammation due to cold for example, fever, sinusitis, high blood pressure, etc. The level of urgency and, hence, appropriate management will vary for the same complaint from one disease to another.

4- Management plan: what to do for this case?

This question is answered at 3 levels: 1) immediate plan, 2) remote plan, and 3) Follow up plan.

The immediate plan is instituted for either therapeutic or prophylactic aspects. It can be omitted when there is no need for it or when the case cannot be yet well judged. Referral of the patient to a more experienced colleague and/ or medical care center is also possible option for immediate management plan. The remote plan may form a further management step or follow certain preparation with or without medications. The follow up plan can be needed for life long or relatively time lasting cases.

5- Clinical session closure:  what to do when you are done?

Considering the appropriate ethics, time and progress of the clinical session, the closure of the session should be smooth and well prepared ensuring that all the medical instructions and treatment plan given to the patient in writing and having the required and ‘allowable’ contact information taken by both physician and patient.

Disease characterization and classification

 

disease characterization

In the medical field, a disease may be regarded as any objectively addressable deviation from the abstract normal. That abstract normal would be assigned a “neutrum” of customarily and/ or scholarly defined state of equilibrium and perfection.

Very remarkable is that the human normal is not shaped, as may be noticed in the phrase above, only by physicians or medical professionals, but also by thinkers, philosophers, scientists, creative minds and the general lay people.

In order for such “disease” to be defined or characterized a few parameters should be fulfilled.

  1. Type of the person in whom this disease may be seen.
  2. Onset of the disease.
  3. Course of the disease.
  4. Associates of the disease.
  5. Common outcome of the disease.
  6. Name of the disease.

These are 6 parameters that would be quite sufficient to characterize a disease on gross and perceivable measures by scholars and the lay as well. The knowledge about the cause(s) and underlying micro changes and molecular mechanisms fall to the interest of a few people including the health care providers.

Let’s talk briefly about each of these disease parameters in hand of common examples.

Type of patient includes:

– Age (child, adolescent, adult, and elderly),

–  Sex (male and female),

– Stature (stunted, average, above average)

– Body shape (slim, average, obese),

– Race (Caucasian, Negroid, Mongolian),

– Personality (easy, strict),

– Acquaintance (poor, average, high).

The relevance of patient’s type to the disease is understood by the fact that some diseases are more common in some patient’s types than in other types.

Onset of the disease

This means how the disease was noticed by the patient or the relatives.

– Sudden onset: the disease has commenced very acutely. Example: a thrombus formation in the leg (deep venous thrombosis, DVT).

– Gradual onset: the disease commence over relatively long time. Example: weakness in the leg due to a disc hernia.

Course of the disease

This describes whether the disease tends to increase, decrease or fluctuate as time passes (over relatively long time) without any interference from the patient’s side.

– Progressive course: e.g. progressive decrease in visual acuity.

– Regressive: e.g. so-called self-limiting disease that resolves gradually by itself such as common cold or flu.

– Intermittent course: this describes a disease that tends to appear from time to time.

Associates of the disease

These imply the relation of the disease to other things like food, drinking, activity, stress, posture, etc. Among the associates of the disease we can consider risk factor(s), e.g. obesity is a risk factor for type 2 diabetes mellitus, and precipitating factor(s), e.g. water restriction is a precipitating factor for renal troubles.

Common outcome of the disease

This is how the disease would most probably set its end.

– Self-limiting, self-curable: usually no treatment is needed.

– Ailing and incapacitating: treatment is needed.

– Life threatening or fatal: treatment is needed.

Name of the disease

This is important because it helps in reliably and efficiently preserving and communicating knowledge about disease.

The terms: “natural history of the disease” and “the full blown picture of the disease”, are helpful in presenting the disease as well characterized entity with its unique components and behavior.

In the realm of disease a classification system may be very necessary in order for easy sorting and recall to be in hand. It is anyhow not an easy job to classify diseases at any known or unknown factor, e.g. their causes. As medical practitioners and students we used to have medical terms such as:

– Infectious diseases and noninfectious diseases

– Organic and psychological diseases

– Genetic and acquired diseases

In addition to other terms like trauma, congenital, psychosomatic and constitutional.

From a practical and treatment-wise approach, I would classify diseases into two main classes: biologic and nonbiologic. In the former class some living organism, e.g. a bacterium, a virus, a parasite such as E. histolytica or a worm, is almost certainly accused for making the disease. In such a case the effects of such biologic invasion must be well assessed and specific treatment may be given as appropriate. Such a microbe- or parasite-oriented treatment may be in some cases life saving as the timely diagnosis and treatment are crucial for favorable outcome. For the latter class of diseases, in which such accusation of an invading organism is quite unlikely to bring about the disease, the treatment will be chiefly concerned with combating the illness through general and/ or specific treatments.

Now,     I wish to present a master for patient’s diagnosis that would be comprehensive and elegant as well:

* Moderate jaundice in otherwise apparently normal 3 days female neonate of type 2 diabetic mother for general treatment and investigation.

* Renal colic in other wise apparently normal 6 years boy for general treatment and investigation.

* Moderate fever (38⁰C) in reportedly hypertensive obese; easy taker 49 male adult for specific antibiotic treatment and advisable investigation.

* Slight Albuminuria (+) in otherwise apparently normal; tense taker 19 weeks primigravida, 32 female adult for mandatory weekly-monthly follow up.

This 5-site patient’s diagnosis comprised: 1) patient’s most relevant complaint or finding, 2) patient’s look and/or medical history, 3) patient’s type, 4) suggested treatment, and 5) investigation.

With the expected advancement of disease characterization more molecular designations will be available for common use that would reflect an increasing awareness of molecularly-oriented medicine.

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