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Medical Decision MakingMedical Decision Making

Presented by:Presented by:

Professor Sameer BafaqeehProfessor Sameer Bafaqeeh

Otolaryngology DepartmentOtolaryngology Department

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Medical Decision MakingMedical Decision Making

Diagnosis/Management OptionsDiagnosis/Management Options Amount/Complexity of DataAmount/Complexity of Data Risks of Complications, Morbidity, Risks of Complications, Morbidity,

MortalityMortality

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Diagnosis/Management OptionsDiagnosis/Management Options

More commonly known to be “problems”More commonly known to be “problems”

- includes identifying whether any of the - includes identifying whether any of the following tests were performed and following tests were performed and assigning the appropriate “points” to them:assigning the appropriate “points” to them:

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Dx/Management Option CategoriesDx/Management Option Categories

• self-limited or minor (problem) self-limited or minor (problem) (1 point) (1 point)

• established problem, stable, improved (1 point)established problem, stable, improved (1 point)

• established problem, worsening (2 points)established problem, worsening (2 points)

• new problem, no additional work-up plannednew problem, no additional work-up planned (3 points) (3 points)

• • new problem, additional work-up plannednew problem, additional work-up planned (4 points) (4 points)

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Amount and/or Complexity of DataAmount and/or Complexity of DataIncludes:Includes: Clinical lab testsClinical lab tests Radiology testsRadiology tests Tests in the Medicine section of CPTTests in the Medicine section of CPT Discussion of test results with performing physiciansDiscussion of test results with performing physicians Decision to obtain old recordsDecision to obtain old records Review and summary of old recordsReview and summary of old records Independent visualizationIndependent visualization

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Risk of Complications, Morbidity, Risk of Complications, Morbidity, MortalityMortality

• Minimal

• Low

• Moderate

• High

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Table of RiskTable of Risk

Refer to handoutRefer to handout

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MDM GridMDM Grid

DX/MgmtDX/Mgmt 0-10-1 22 33 4+4+DataData 0-10-1 22 33 4+4+

RiskRisk MinMin LowLow ModMod HighHigh

Type ofType of

DecisionDecision

MakingMaking

StfwdStfwd LowLow ModMod HighHigh

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ExamplesExamples

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Self limited or minorSelf limited or minor

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6 y/o female presents with 2 small6 y/o female presents with 2 smallraised areas on R thigh. No fever.raised areas on R thigh. No fever.

Exam:Exam:GEN: alert, NADGEN: alert, NADHEENT: TM’s normal, Nares- clearHEENT: TM’s normal, Nares- clearHEART: RRRHEART: RRRLUNGS: CTALUNGS: CTAABD: SoftABD: SoftEXT: Normal with exception of 2-pin point, slightly red, EXT: Normal with exception of 2-pin point, slightly red, raised areas on R thighraised areas on R thigh

Dx: Insect bite Dx: Insect biteReturn to clinic if problem occursReturn to clinic if problem occurs

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Established problem, stable, Established problem, stable, improvedimproved

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Patient is a 55 year old establishedPatient is a 55 year old establishedpatient who returns today for follow-uppatient who returns today for follow-upof his hypertension. He has done wellof his hypertension. He has done wellsince last visit w/o symptomssince last visit w/o symptomsconsistent w/angina or congestiveconsistent w/angina or congestiveheart failure.heart failure.

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Established problem, worseningEstablished problem, worsening

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CC: still with abdominal painCC: still with abdominal pain

6 yr old with persistent abdominal pain6 yr old with persistent abdominal painthat started initially with vomiting andthat started initially with vomiting andfever. Going on 3 weeks. Tums hasfever. Going on 3 weeks. Tums hasnot improved pain. No diarrhea. Painnot improved pain. No diarrhea. Painnow epigastric.now epigastric.

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New problem, no additional New problem, no additional work-up plannedwork-up planned

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60 yr old WM white bumps on face, has60 yr old WM white bumps on face, hashad several milia removed in the past.had several milia removed in the past.C/O small area on left side of nose.C/O small area on left side of nose.

No bleeding, no itching, no history ofNo bleeding, no itching, no history ofskin cancer. Allergic to sulfa drugs.skin cancer. Allergic to sulfa drugs.

Exam:Exam:L nasal bridge - skin colored papule with L nasal bridge - skin colored papule with sebaceous glands & pore accentuationsebaceous glands & pore accentuationForehead and nasolabial fold – white smooth Forehead and nasolabial fold – white smooth papule/pustulepapule/pustuleL cheek - irritated scaly 4 mm papuleL cheek - irritated scaly 4 mm papuleChest – erythematous vesicular papuleChest – erythematous vesicular papule

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1.1. Prob Sebaceous Hyperplasia- reassurance return Prob Sebaceous Hyperplasia- reassurance return if changesif changes

2.2. MiliaMilia

3.3. SK – reassuranceSK – reassurance

4.4. Cherry angioma – reassuranceCherry angioma – reassurance

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New problem, additional New problem, additional work-up plannedwork-up planned

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58 y/o female presents with B anterior thigh pain 58 y/o female presents with B anterior thigh pain when walking short distances.when walking short distances.

Exam: Exam: Cranial nerves: intactCranial nerves: intactReflexes: intactReflexes: intactSensation: intact to touch/vibrationSensation: intact to touch/vibrationStrength: decreased in Quads with some Strength: decreased in Quads with some atrophy noted atrophy noted

MRI orderedMRI orderedNCV/EMG ordered for eval of nerves L3 & L$NCV/EMG ordered for eval of nerves L3 & L$

Dx: Pain in limbDx: Pain in limb