CRP 4-K2 Asking Answerable Clinical Question
Transcript of 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
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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
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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
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#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$, im&act and a&&licabilit$
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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 $o we actuall% &ractice !M"'''
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Scenario
0 &ediatrician #as called t! te !s&ital t! attendte deliver$ !" 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.
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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.
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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.
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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
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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$, #ill e be "ineA
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0m!n &atients &resentin =!# 0P>0?
SC@?E, !# !"ten #!uld devel!&
neur!l!ical c!m&licati!nsA In babies #it =!# 0P>0? SC@?E, #!uld
j!inin an interated sel" care &arents
manaement &r!ram reduce m!rbidit$
"r!m abn!rmal mental ca&acit$ !ver /-
$earsA
Questions
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!ackgroun$ 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,!#, #$) and a verb
. 0 dis!rder, test, treatment !r !ter as&ect!" ealt care
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!ackgroun$ an$ .oregroun$Questions
F!rer!und questi!ns
0s% "!r s&eci"ic %n!#lede t! in"!rm clinical
decisi!ns !r acti!ns
<ave "!ur essential c!m&!nents+
*. Patient and6 !r &r!blem (P)
. Interventi!n !r e'&!sure (I)
. C!m&aris!n, i" relevant (C)
. Clinical !utc!mes includin time i" relevant (O)
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A B C
Background
Foreground
xperience !ith Condition
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0 limited e'&erience #it te c!nditi!n B as #e r!# in clinical e'&erience and
res&!nsibilit$ 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
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/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
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/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.
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;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
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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.
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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"$in !ur &atientGs illnesses
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Di""erential dian!sis Dian!stic tests
Pr!n!sis 1era&$ Preventi!n
E'&erience and meanin Im&r!vement !# t! %ee& u&-t!-date
Central issues in clinical work whereclinical 0uestions oten arise
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.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
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3ell d!ne4
%ee&in &ractice