crp 4-k2 asking answerable clinical question

7/23/2019 CRP 4-K2 Asking Answerable Clinical Question

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Asking AnswerableClinical Questions

(DM-K2-CRP4)

dr. Isti Ilmiati Fujiati, MSc.CM-FM, MPD



What is !M"

Evidence-based medicine (EBM) requires

te integration !" te best research

evidence #it !ur clinical expertise and !ur patient’s unique values and circumstances



Best research evidence means valid andclinicall$ relevant researc

Clinical expertise means abilit$ t! use !urclinical s%ills and &ast e'&erience t! ra&idl$identi"$ eac &atients unique ealt state anddian!sis

Patient values means te unique &re"erences,c!ncerns and e'&ectati!ns eac &atiens bris t!a clinical enc!unter and #ic must be interatedint! clinical decisi!ns i" te$ are t! serve te

&atient Patient's circumstances means teir individual

clinical state and clinical settin



#ow $o we actuall% &ractice !M"

Ste&-*+ c!nvertin te need !" in"!rmati!n (ab!ut &reventi!n, dian!sis, &r!n!sis,tera&$, causati!n, etc.) int! an ans#erablequesti!ns

Ste&-+ trac%in d!#n te best evidence #it #ic t! ans#er tat questi!n

Ste&-+ criticall$ a&&raisin tat evidence"!r its validit$, im&act and a&&licabilit$



Ste&-+ interatin te critical a&&raisal #it

!ur clinical e'&ertise and #it !ur &atients

unique bi!l!$, values, and circumstances Ste&-/+ evaluatin !ur e""ectiveness and

e""icienc$ in e'ecutin ste&s *- and

see%in #a$s t! im&r!ve tem b!t "!r ne't

time

#ow $o we actuall% &ractice !M"'''



Scenario

0 &ediatrician #as called t! te !s&ital t! attendte deliver$ !" a ne# b!rn. 1e m!ter, a 2 $ear

!ld &rimiravida, ad e'&erienced elevated bl!!d

&ressure durin an !ter#ise unc!m&licated

&renanc$. 1e lab!r #as induced because te&renanc$ ad c!ntinued #ee%s &ast te

e'&ected date !" deliver$. Durin lab!r, evidence

!" "etal distress !ccurred. 3en te membranes

ru&tured, te !bstetrician n!ted tic% reenisc!ntainin mec!nium.



0t te time !" deliver$4

te male ne#b!rn #as lim& and c$an!tic, and ad

n! s&!ntane!us res&irat!r$ e""!rt and a eart rate!nl$ /5 beats6 min. 3en mec!nium #as

sucti!ned "r!m is m!ut and n!se, te bab$ did

n!t rimace, c!u, !r snee7e.

8i!r!us e""!rt at resuscitati!n #ere initiated,includin ba-and-mas% ventilati!n #it *559

!'$en and cest c!m&ressi!ns, but te 0&ar

Sc!re at * min. !" li"e #as *. Des&ite c!ntinuin

resuscitati!n, te / min. 0&ar sc!re im&r!ved

!nl$ t! , #it a eart rate !" **5 beats6 min.



1e *5 min. 0&ar sc!re remained de&ressed

at , and te ne!nate #as trans"erred t! te

:e#b!rn Intensive Care ;nit. 3itaressive medical manaement, te *55

ram ne!nate c!ntinued t! im&r!ve #it!ut

evidence !" acute neur!l!ic c!m&licati!ns.

<e #as discared "r!m te !s&ital !n te

t#el"t da$ !" li"e.



A&gar core or *aluation o +eonatal As&h%,ia

Score

Sign 0 1 2

Heart Rate (x/ min)

Respiration

Muscle Tone

Color

Reflex response tocatheter in nostril

(-)

(-)

Limp

Blue, pale

one

! "##

Slo$, irregular

Slo$ flexion

Bo%& pin',

extremities lue

rimace

*"##

Regular, cr&ing

+ctie motor

Completel& pin'

Cough, sneee



Questions

3at are te c!m&licati!ns !" =!# 0P>0?

SC@?EA

<!# d!es te =!# 0P>0? SC@?E lead t!neur!l!ical c!m&licati!nsA

3at did te &atient mean b$ i" m$ bab$

can n!t cr$ immediatel$, #ill e be "ineA



0m!n &atients &resentin =!# 0P>0?

SC@?E, !# !"ten #!uld devel!&

neur!l!ical c!m&licati!nsA In babies #it =!# 0P>0? SC@?E, #!uld

j!inin an interated sel" care &arents

manaement &r!ram reduce m!rbidit$

"r!m abn!rmal mental ca&acit$ !ver /-

$earsA

Questions



!ackgroun$ an$ .oregroun$

QuestionsBac%r!und questi!ns 0s% "!r eneral %n!#lede ab!ut a

c!nditi!n !r tin <ave t#! essential c!m&!nents+

*. 0 questi!n r!!t (#!, #at, #ere, #en,!#, #$) and a verb

. 0 dis!rder, test, treatment !r !ter as&ect!" ealt care



!ackgroun$ an$ .oregroun$Questions

F!rer!und questi!ns

0s% "!r s&eci"ic %n!#lede t! in"!rm clinical

decisi!ns !r acti!ns

<ave "!ur essential c!m&!nents+

*. Patient and6 !r &r!blem (P)

. Interventi!n !r e'&!sure (I)

. C!m&aris!n, i" relevant (C)

. Clinical !utc!mes includin time i" relevant (O)



A B C

Background

Foreground

xperience !ith Condition



0 limited e'&erience #it te c!nditi!n B as #e r!# in clinical e'&erience and

res&!nsibilit$ C "urter e'&erience #it te c!nditi!ns Dia!nal line s!#s #ere never t!! reen

t! learn "!rer!und %n!#lede !r t!!e'&erience t! !utlive te need "!rbac%r!und %n!#lede



/ur reactions to knowing an$to not knowing

Clinical &ractice demands tat #e use lare

am!unts !" b!t bac%r!und and "!rer!und

%n!#lede, #eter !r n!t #ere a#are !" its use.

C!mbinati!ns !" &ractice demands and !ur

a#areness+

*st !ur &atients &redicament ma$ call "!r

%n!#lede tat #e alread$ &!ssess, s! #e #ille'&erience te rein"!rcin mental and em!ti!nal

res&!nses termed C!nitive ?es!nance



/ur reactions to knowing an$to not knowing

nd #e ma$ reali7e tat !ur &atients illness calls"!r %n!#lede tat #e d!nt &!ssess, and tisa#areness brins mental and em!ti!nal

res&!nses termed C!nitive Diss!nance needto know

rd - !ur &atients &redicament mit call u&!n%n!#lede tat #e d!nt ave, $et tese a&s

ma$ esca&e !ur attenti!n, s! #e d!nt %n!# #at#e d!nt %n!# and #e carr$ !n undisturbedignorance.



;n"!rtunatel$4

i" andled less #ell, !ur c!nitive

diss!nance mit lead us t! less ada&tivebeavi!rs suc as tr$in t! ide !ur

de"icits, !r b$ reactin #it aner, "ear, !r

same



B$ devel!&in a#areness !" !ur %n!#in

and tin%in, #e can rec!ni7ed !ur

c!nitive diss!nance #en it !ccurs,rec!ni7ed #en te %n!#lede #e need

#!uld c!me "r!m clinical care researc,

and articulate bac%r!und and "!rer!und

questi!ns #e can use t! "ind te ans#ers.



Central issues in clinical work whereclinical 0uestions oten arise

Clinical "indins !# t! &r!&erl$ ater and

inter&ret "indins "r!m te ist!r$ and &$sical

e'aminati!n

Eti!l!$ !# t! identi"$ causes !r ris% "act!rs

(includin iatr!enic arms)

Clinical mani"estati!n !" disease %n!#in

!# !"ten and #en a disease causes its clinicalmani"estati!ns and !# t! use tis %n!#lede in

classi"$in !ur &atientGs illnesses



Di""erential dian!sis Dian!stic tests

Pr!n!sis 1era&$ Preventi!n

E'&erience and meanin Im&r!vement !# t! %ee& u&-t!-date

Central issues in clinical work whereclinical 0uestions oten arise



.or %ou to ha*e the skills in0uestioning

Ma%e an ans#erable clinical questi!ns(bac%r!und !r "!rer!und questi!n)

;se $!ur %n!#lede in semester *, , ,and6 !r t! ma%e te questi!n. H!u can c!!se te scenari! "r!m !ne !"

te triers in 1ut!rial t! el& $!u "!rmulate

te questi!ns "ou have # minutes to do this exercise



3ell d!ne4

%ee&in &ractice

crp 4-k2 asking answerable clinical question

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