ASKING ANSWERABLE CLINICAL QUESTION

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ASKING ANSWERABLE CLINICAL QUESTION
Akbar soltani. MD, MSc Tehran University of
Medical Sciences (TUMS) Endocrine and Metabolism
Research Center (EMRC) Evidence-Based Medicine
research Center (EBMRC) Shariati
Hospital www.soltaniebm.com www.ebm.ir
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Outline

• Background and foreground question
• Asking question and research methodology
• What is PICO?
• What is educational prescription?

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?????

• ?? ???? ????? ???? ? ??? ???? ?? ?? ??? ????? ?
  ????? ????? ??? ???. ???? ?? ??? ???? ???? ?? ??
  ??? ? ?????? ???? ?????? ?? ??? ????? ?? ? ????
  ??? ?? ??? ????? ???? ???? ?????? ??? ?? ???? ??
  ????? ?? ?? ????? ???? ??? ????.

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??????

• ?? ???? ??? ?????? ?? ????? ?? ????? ???? ? ???
  ????? ( ?? ?????) ??????? ?? ?? ?? ??? ???? ???
  ???? ???? ??? ?? ?? ???? ???? ???????? ????.

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• Background Q is about general knowledge not
  specific cases
• Back ground Q is related to disease not patients?
• K answer is not important, what is the kind of
  answer is more important
• Questions
• analytic
• empirical
• normative
• So, for every types we have specific type of
  answer

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Which answer is appropriate for different types
of questions?

• Analytic answers are based on definitions,
  tautologies, A priori,
• Empirical answers are based on experiments
• Normative based on metaethics?

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A five-step process for using an evidence-based
approach in general practice

1. Define the problem
2. Track down the information sources you need
3. Critically appraise the information
4. Apply the information with your patients
5. Evaluate how effective the application of
   information is

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The First Step in EBM

• Develop a well-built, structured,
• answerable clinical question

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Answerable Question

• ANSWERABLE means not subjective and . Because
  if you ask a subjective question from your
  colleagues s/he would answer because s/he catch
  the question but databases do not catch as they
  are not human!
• So you should ask an answerable questions
• Principally subjective / vague, could not be
  understand definitely so could not be answered
  correctly

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Gaps in our medical knowledge a source of our
clinical questions

• Range from miniscule to complete lack of
  familiarity with the patients need.
• Negative response
• Anxiety, shame, burnout
• Positive response Embrace our opportunity to
  learn
• Asking questions
• Searching for answers
• Channeling nervous energy into useful work

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Where do the clinical questions come from?

• Therapy
• Diagnostic Test
• Clinical Findings
• Etiology
• Differential Diagnosis
• Prognosis
• Prevention
• Self-improvement

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A clinical scenario

• The patient is a 77-year-old man admitted for
  dyspnea and fever. He fell ill 4 days ago with
  low-grade fever, chills, myalgias, rhinorrhoea
  and a non-productive cough. One day ago he
  developed dyspnea on exertion, purulent sputum,
  lateral chest wall pain with inspiration and a
  shaking chill. His general health is fairly
  good He has had essential hypertension for 12
  years, well controlled on diuretic therapy. He
  has not smoked.

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A clinical scenario (cont.)

• On examination, his respiratory rate is 28, his
  heart rate is 108 and his temperature is 39.2C.
• He have subtle cyanosis
• His chest expands symmetrically
• He has no wheezing
• There is bronchophony and egophony in the left
  lower posterior lung field.

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A clinical scenario (cont.)

• Initial blood tests show leukocytosis and
  hyponatremia.

• The team suspects acute community-acquired
  pneumonia with hypoxemia, and plans chest
  radiographs, sputum studies, supplemental oxygen
  and antimicrobial therapy

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• what are your questions
• about this case?

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A medical students questions

• What microbial organisms can cause
  community-acquired pneumonia?
• How does pneumonia cause egophony?
• What is the incidence of community-acquired
  pneumonia?

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Background question

• Notice that the students questions ask for
  general or background knowledge about
  pneumonia, the disorder that explains much of
  this patients acute illness.
• Epidemiology, Prevalence, Incidence,
  Pathophysiology, (as in the first parts of
  textbooks)

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• Background questions
• Ask for general knowledge about a disorder
• Two essential components
• A question root (who, what, where, when, how)
• A disorder, or an aspect of a disorder

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A practitioners questions

• In this patient, are clinical findings
  sufficiently powerful to rule in or rule out
  pneumonia?(Dx)
• In this patient, is a Chest X-Ray necessary for
  the diagnosis?(Dx)
• In this patient, is the probability of Legionella
  infection sufficiently high to warrant
  considering coverage of this organism using
  initial antibiotic choice? (Tx)
• In this patient , do clinical features predict
  outcome well enough that as a low risk patient,
  he can be treated safely at home?

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Foreground question

• These questions ask for specific knowledge about
  diagnosis, prognosis, and treatment of patients
  with pneumonia, which might be called
  foreground knowledge.
• Due to high turnover of foreground Q, always we
  have foreground Q and we should search in
  opposite to background Q

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• Foreground
• The patient and/or the problem
• The main intervention (defined very broadly,
  including an exposure, a diagnostic test, a
  prognostic factor, a treatment, a patient
  perception,)
• Comparison intervention
• The clinical outcome .

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Foreground Questions
Background Questions
Experience
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• Questions
• When did you publish your last paper?
• When did you begin your study?
• When was you paper accepted?
• When was the new textbook renewed?
• So, text books are not perfect resource to find
  foreground Q

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Hallmarks of a good question

• Relevant - Will the answer matter?
• Answerable - Can the question be answered by
  research data?
• Clear unambiguous, definite, objective
• Worthy - Is the answer worth the work?

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Formulating a clinical question

• This skill can be improved by
• Breaking the question down into its component
  parts
• Classifying the question into a specific domain
• therapy, diagnosis, prognosis, harm

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Using the question to guide searching

• Scenario - You are interested in checking the
  hearing of elderly patients, and have heard that
  the whispered voice test is good.
• Question
• Population in elderly patients does
• Indicator a poor whispered voice test
• Comparator a normal whispered voice test
• Outcome predict abnormal audiogram

1. Underline the key terms
2. Number the order of importance from 1-4
3. Think of alternate spellings, synonyms,
   truncations

Paul Glasziou
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Using the question to guide searching

• Scenario - You are interested in checking the
  hearing of elderly patients, and have heard that
  the whispered voice test is good.
• Question
• Population in elderly patients does
• Indicator a poor whispered voice test
• Comparator a normal whispered voice test
• Outcome predict poor hearing (audiogram)

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1
2

1. Underline the (root of the) key terms
2. Number the order of importance from 1-4
3. Think of alternate spellings, synonyms,
   truncations

Paul Glasziou
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Check the question type
Check the emphasis
AND means both terms required
Means any other letters
Paul Glasziou
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Stepwise searching

• Search with 1 PICO item
• Whisper
• Then go to Clinical Queries diagnosis
• Whisper (again)
• Add 2 PICO item
• whisper AND (hear OR audiogram)

Paul Glasziou
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Combining terms with Boolean operators AND
IN CAPITALS
weight AND chitosan - has both terms
weight
chitosan
Paul Glasziou
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Combining terms with Boolean operators OR
weight OR chitosan - has either term
weight
chitosan
Paul Glasziou
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Your tasks

• Search for the best single article (systematic
  review or trial) for
• Your question from notes
• Your own question(s)
• When you are finished
• Print just the abstract for each
• Write your search strategy on the page

Paul Glasziou
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Boo-le-ans

• AND both terms
• OR either term
• NOT not this term
• (ADJacent, NEAR, AND close)

George Boole (a man) is claimed to have
invented logic
Paul Glasziou
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Where to the brackets go?

• If you want
• cheese AND fruit
• Which do you ask for?
• cheese AND (apple OR pear OR melon)
• (cheese AND apple) OR pear OR melon
• What does PubMed do with if AND and OR?
• Cheese AND apple OR pear
• (Look at DETAILS tab)

Paul Glasziou
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General structure of search

• (Population OR synonym 1 OR ) AND
• (Intervention OR synonym 1 OR ) AND
• (Comparator OR synonym 1 OR ) AND
• (Outcome OR synonym 1 OR ) AND
• FILTER (for best study type)

Paul Glasziou
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Check the question type
Check the emphasis
AND means both terms required
Means any other letters
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Your tasks

• Search for the best single article (systematic
  review or trial) for
• Your question from notes
• Your own question(s)
• When you are finished
• Print just the abstract for each
• Look at methodology
• Write your search strategy on the page

Paul Glasziou
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Common types of questions and related evidence

• Causation / Etiology
• Cohort gt Case Control gt Case series gt Case
  reports
• Diagnosis
• Cross-sectional gt and/or cohort gt case controls

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Common types of questions and related evidence
(cont.)

• Therapy
• Systematic review of RCTs gt RCT gt Cohort,
  Case-control gt Expert Opinion
• Prognosis
• Cohort gt Case-control,

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Types of question stroke
Cohort Study
Inception Cohort Study
Survey
Frequency
Prognosis
Risk Factors
Treatments Randomised Trial
Treatment Effect
Symptoms Signs, Tests
Cause(s)
Past current
future
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Types of EvidenceQuestion Types
Type of Question Best Evidence
Health care interventions treatment, prevention Quantitative Systematic Review of RCTs or RCT
Harm or Etiology Quantitative Observational Study - Cohort or Case Control
Prognosis Quantitative Observational Study - Cohort, Case Control
Diagnosis or Assessment Quantitative Comparison to Gold Standard
Economics Quantitative Cost-effectiveness Study
Meaning Qualitative case study, ethnography, grounded theory, phenomenologic approach
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Question components PICO

• What types of Participants?
• What types of Interventions?
• What types of Comparison?
• What types of Outcomes?

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What Types of Participants?

• (Patient / Population)
• Disease or condition of interest
• Potential co-morbidity
• Setting
• Demographic factors

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First component

• Think about who / what you wish to apply this
  evidence to e.g.
• People with a particular disorder?
• e.g chronic recurrent cystitis
• People in a particular care setting?
• e.g. community
• particular groups of people
• e.g. sexually active young women?
• the elderly?
• children?
• How would you describe your clients / setting?

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What Types of Intervention?

• Type of treatment
• Type of diagnostic test
• Type of causative agent
• Type of prognostic factor

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Second component

• The intervention / topic of interest (e.g. cause,
  change in practice etc.) e.g.
• Use of cranberry juice (as a drink)
• Might want to specify how much / how often
• For complex interventions may need to give
  specific detail / consideration to the
  description
• What exactly am I considering?

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Third component

• The comparison or alternative (not applicable to
  all questions) e.g.
• Anti-biotic therapy?
• Nothing?
• Fluids alone?
• What alternatives actions might I try?

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Fourth component

• The outcome e.g.
• Cure
• Duration of disease
• prevention
• Death
• Side effects
• Pain (reduced)
• Wellbeing
• What am I hoping to accomplish (what outcomes
  might reasonably be affected)?

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Patient oriented outcomes

• Mortality/Survival
• Disease free period
• Quality of life
• Work absenteeism
• Disability/ Duration and severity of illness
• Pain

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What Types of Outcome?

• For treatment, it includes all outcomes that are
  important to people, and lead to make decisions
  to define success of therapy
• For prognosis, outcome is the chosen endpoint of
  the disease
• (Mortality, Morbidity, Quality of life
  Disease-free period, admission period, pain, work
  absence,)
• Outcomes
• Patient oriented
• Disease oriented

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O Outcomes

• POEM Patient Oriented Evidence that Matters
  (Foreground)
• DOE Disease Oriented Evidence (Background)

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Examples of Hypothetical DOE and POEM studies
Drug A lowers cholesterol
Drug A lowers cardiovascular mortality
Drug A decreases overall mortality
Fouride increase osteoblast ic activity
Fuoride increse BMD
Fluoride increase fracture
Tight control of type 1 Diabetes decreases
mortality and improves quality of life
Tight control of type 1 diabetes mellitus keeps
FBSlt140mg/dl
Tight control of type 1 Diabetes decreases
Microvascular complications
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Patient oriented outcomes

• Mortality/Survival
• Disease free period
• Quality of life
• Work absenteeism
• Disability/ Duration and severity of illness
• Pain

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Common Types of Questions

1. Diagnosis
2. Therapy
3. Prognosis
4. Causation / Etiology

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Treatment

• P In a child with frequent febrile seizures
• I would anticonvulsant therapy
• C compared to no treatment
• O result in seizure reduction?

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Diagnosis

• P In an otherwise healthy 7-year-old boy with
  sore throat,
• I - how does the clinical exam
• C compare to throat culture
• O in diagnosing Streptococcal infection?

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Diagnosis

• P In a 15 month old child with FTT
• I is IgA antigliadin antibodies
• C comparable to biopsy
• O in diagnosing celiac disease?

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Example

• A TV programme has highlighted a hospital in
  Suffolk in which a stroke unit has been set up
  that specialises in the treatment of patients who
  have suffered strokes.
• The hospital trust wants to know about the
  effectiveness of stroke units in terms of lives
  saved before deciding whether to invest in one.

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Patient Or Problem Intervention Comparison Outcomes

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Patient Or Problem Intervention Comparison Outcomes
Patients who have suffered strokes
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Patient Or Problem Intervention Comparison Outcomes
Patients who have suffered strokes Stroke units
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Patient Or Problem Intervention Comparison Outcomes
Patients who have suffered strokes Stroke units Normal hospital care
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Patient Or Problem Intervention Comparison Outcomes
Patients who have suffered strokes Stroke units Normal hospital care Lives saved
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Or
Do stroke units save lives ?
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Example

• A acute cough is a common reason for patients to
  consult their GP. The causes of acute cough
  varies a lot. In GP the treatment often includes
  antibiotics.
• The effectiveness of Abx is questionable and
  there has been a great deal of concern about
  bacterial resistance from over-prescribing.

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Patient Or Problem Intervention Comparison Outcomes

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Patient Or Problem Intervention Comparison Outcomes
Acute Cough in primary care setting
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Patient Or Problem Intervention Comparison Outcomes
Acute Cough in primary care setting Antibiotics
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Patient Or Problem Intervention Comparison Outcomes
Acute Cough in primary care setting Antibiotics No antibiotics
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Patient Or Problem Intervention Comparison Outcomes
Acute Cough in primary care setting Antibiotics No antibiotics Duration and severity of illness
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Prognosis

• P - In children with Down syndrome,
• I - is IQ an important prognostic factor
• C
• O in predicting Alzheimers later in life?

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Prognosis

• P In a 14 year old teen with a low grade
  frontal oligodendroglioma, who is symptom free
• I receiving standard therapy,
• C
• O what is life expectancy?

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Etiology/Harm

• P Controlling for confounding factors, do
  otherwise healthy children
• I - exposed in utero to cocaine,
• C compared to children not exposed
• O have increased incidence of learning
  disabilities at age six years?

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Etiology/Harm

• P Does a newborn
• I given vitamin K at birth
• C compared to no vitamin K
• O have an increase in cancer later in life?

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Is PICO effective?

• Use of PICO-structured forms resulted in more
  complex search strategies (P 0.002)
• Clinical requests handled by PICO-structured form
  resulted in fewer items retrieved (P 0.028)
  i.e. more specific searches.
• Librarians preferred minimally structured forms
  to PICO-structured forms in every dimension
  except informativeness.
• (Booth A, et al. Structuring the pre-search
  reference interview a useful technique for
  handling clinical questions. Bull Med Libr Assoc.
  2000 Jul88(3)239-46)

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Is PICO effective?

• Only 20 of questions the intervention and the
  control groups were properly specified from at
  baseline.
• 7/14 questions previously mis-specified in the
  intervention group were properly specified at
  follow-up (P 0.008). Control group showed no
  changes from baseline.
• Intervention group more likely to explicitly
  describe patients (P 0.028), comparisons (P
  0.014), and outcomes (P 0.008).
• (Villanueva EV, et al. Improving question
  formulation for use in evidence appraisal in a
  tertiary care setting a randomised controlled
  trial. BMC Med Inform Decis Mak. 20011(1)4.
  Epub 2001 Nov 08.)

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Should I ask a colleague?

• 12 occupational therapy questions
• E.g., Is a 38-year old sewage worker subject to a
  higher risk of contracting Hepatitis A as a
  result of occupational exposure? (No)
• Obtain advice from 2 professionals on 3 cases
  each.
• 37 wrong answers
• 17 wrong if based on literature
• 65 wrong if not

Schaafsma BMC Health Services Research 2005
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Impact of searching on correctness of answers to
clinical questions
Right to Right Wrong to Right Right to Wrong Wrong to Wrong
McKibbon (GP or IM) 28 13 11 48



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Impact of searching on correctness of answers to
clinical questions
Right to Right Wrong to Right Right to Wrong Wrong to Wrong
McKibbon (GP or IM) 28 13 11 48
Quick Clinical (GPs) 21 32 7 40
Hersh (Med students) 20 31 12 36
Hersh (Nursing) 18 17 14 52
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Deciding which question to answer first

1. What is the most important issue for this
   patient now?
2. Which question, when answered, will help me
   most? (Has direct and significant impacts on
   decision-making)
3. Most likely recur in my practice?

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Example

• A acute cough is a common reason for patients to
  consult their doctors. The causes of acute cough
  varies a lot. the treatment often includes
  antibiotics.
• The effectiveness of Abx is questionable and
  there has been a great deal of concern about
  bacterial resistance from over-prescribing.
• Convert the problem to an answerable question
  (30 seconds)

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Example

• Patient
• Acute Cough in primary care setting
• Intervention
• Antibiotics
• Comparison
• No antibiotics
• Outcomes
• Duration and severity of illness

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My 1 yr old just had a febrile seizure - what
will happen to her in future?

• Patient
• In children 6mo-6yrs who have had febrile seizure
• Intervention
• (Exposure) a first febrile seizure
• Comparison
• No febrile seizure
• Outcomes
• the likelihood of recurrent febrile seizures
  epilepsy neurologic damage?

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Scenario

• A 44-year-old woman with recently diagnosed
  ovarian cancer presents to the emergency room
  with dyspnea and inspiratory chest discomfort.
• The ventilation-perfusion scan is read as
  indeterminate.
• The emergency room doctor asks your advice.

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Scenario

• When compared with pulmonary angiography, how
  well does an indeterminate result of a
  ventilation-perfusion scan rule out pulmonary
  embolism in a patient with a high pretest
  probability?
• Convert the problem to an answerable question
  (15 seconds)

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Scenario

• Patient
• Woman with Ovarian cancer, dyspnea
• Intervention
• Ventilation-Perfusion scan
• Comparison
• Pulmonary Angiography
• Outcomes
• Pulmonary Embolism

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Broad or narrow questions?

• Broad
• Do drug X reduce mortality and morbidity in
  people with severe malaria?
• Narrow
• Do drug X suppositories reduce mortality in
  children with cerebral malaria?

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What is the Best Treatment for Zoster?

• What is the most cost-effective treatment for
  zoster if we consider pain reduction, quality of
  life and prevention of post-herpetic neuralgia?
• Is famciclovir effective at preventing
  postherpetic neuralgia (defined as pain 3 months
  after rash healing) in otherwise healthy patients
  aged 60-70 who present within 48 hours of zoster
  rash, compared with placebo?

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Example 1
You admit a 65 year old man with a stroke. On
examination you find that he has mild weakness of
the right arm and right leg and bilateral carotid
bruits. You send the patient for carotid doppler
ultrasonography and subsequently receive the
report that he has moderate stenosis (50-69 by
NASCET criteria) of the ipsilateral carotid
artery. You've noticed in the pile of journals
that is accumulating in your office that there
has been some recent literature addressing
surgical versus medical (ASAacetylsalicylic
acidAspirin) therapy for patients with
symptomatic carotid stenosis but you are unsure
what the results of these studies indicate. A
clinician could ask the following questions 1.
Can ASA (acetylsalicylic acid, Aspirin) decrease
the risk of stroke? 2. Does a carotid bruit
predict significant carotid stenosis? 3. How
effective is a carotid endarterectomy in someone
with moderate carotid stenosis? How can we make
well-built clinical questions from these clinical
dilemmas?
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Example 1. Prevention
Patient or Problem 65 year old man with a stroke and moderate carotid stenosis
Intervention ASA
Comparison placebo
Outcome stroke
Question In a 65 year old man with a stroke and moderate carotid stenosis, can ASA decrease the risk of another stroke compared with no treatment?
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Example 1. Diagnosis
Patient or Problem 65 year old man with a stroke
Intervention carotid bruit
Comparison doppler ultrasonography
Outcome carotid stenosis
Question In a 65 year old man with a stroke, how precise and accurate is the presence of an ipsilateral carotid bruit for diagnosing significant carotid stenosis compared with doppler ultrasonography?
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Example 1. Therapy
Patient or Problem 65 year old man with a stroke and moderate carotid stenosis
Intervention carotid endarterectomy
Comparison ASA
Outcome stroke
Question In a 65 year old man with stroke and moderate carotid stenosis, can carotid endarterectomy decrease the risk of stroke compared with medical therapy?
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Example 2
You admit a 75 year old man with a stroke (left
sided weakness) who is having trouble ambulating,
feeding, bathing and dressing himself. He has
hypertension but it is well controlled with a
diuretic. He is otherwise well and now that he is
medically stable you decide after discussion with
him to transfer him to a stroke unit. His family
asks to see you because they are concerned about
this transfer. They live very close to the acute
care hospital and wonder why he can't stay on the
general medical ward where he currently is. You
arrange to meet with him and his family to
discuss their concerns. In the meantime, you
decide to review the evidence for the use of
stroke units. What clinical questions could you
ask?
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Example 2
Patient or Problem 75 year old man with a stroke and residual weakness
Intervention admission to a stroke unit
Comparison general care
Outcome functional status
Question In an elderly man with a stroke, does admission to a stroke unit decrease the risk of death and dependency?
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Example 3
You are a GP. Your middle-aged patient comes to
see you because of painful, weak, and stiff left
shoulder. A few days ago, while lifting some
heavy furniture, he felt a pop in the shoulder.
You suspect a rotator cuff tear and send him to
an orthopedic specialist. Your patient returns
after a couple of days, angry because the doctor
at the hospital first ordered an MRI, but since
the machine was not operational he used the
ultrasound, ensuring your patient that its all
the same. Your patient doesnt believe this to
be a valid diagnosis. Can you, by reviewing
evidence of diagnostic procedures in such cases,
persuade him to see the specialist again? What
clinical questions could you ask?
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Example 3
Patient or Problem middle-aged man with a rotator cuff tear
Intervention ultrasound
Comparison MRI
Outcome diagnosis
Question Is diagnostic ultrasound imaging as accurate as MRI in detecting partial thickness rotator cuff tear in middle age?
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Example
You admitted 4 year old boy with the diagnosis of
bacterial meningitis. Blood tests revealed
existence of IgM-class antibodies reactive to
antigens from H. influenzae. You wondered how
sure can you only by this test confirm the
diagnosis, but despite that questions, soon after
taking blood sample for hemoculture, you
introduced therapy with antibiotics. You are
familiar with the fact that 20 of cases of
meningitis caused by H. influenzae result in
complete or partial hearing loss. You also
remember that you read somewhere that risk of
this sequel may be lowered by application of
dexamethasone. Ask clinical question, search the
literarture, and appraise the results?
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Asking clinical question
Patient or Problem 4 year old man with H. influenzae meningitis
Intervention antibioticsdexamethasone
Comparison antibiotics only
Outcome hearing losss
Question In a 4 year old boy with H. influenzae meningitis, does application of dexamethasone decreases the risk of partial or complete hearing loss?
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Educational Prescription

• Date and place to be filled___________
• Educational tasks to be completed before session
• Learner_________ Task___________
• 
  ___________
• 
  ___________
• Presentations will cover
• How you found what you found
• What you found
• The validity and applicability of your find
• How it will alter your management
• How well you think you did

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Advantages of the educational prescription

• It specifies the clinical problem that generated
  the question.
• It states the question, in all of its key
  elements.
• It specifies who is responsible for answering it.
• It reminds everyone of the deadline for answering
  it (taking into account the urgency of the
  clinical problem that generated it).
• Finally, it reminds everyone of the steps of
  searching, critically appraising and relating the
  answer back to the patient.

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• One tactic we use is to make specifying clinical
  questions an integral part of presenting a new
  patient to the group.
• For example, we ask learners on our general
  medicine in-patient clinical teams, when
  presenting new patients, to tell us 33 things in
  3 minutes about each admission.

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• the final element of their presentations is the
  specification of an important question to which
  they need to know the answer and dont.
• If the answer is vital to the immediate care of
  the patient, it can be provided at once by
  another member of the clinical team
• Most of the time the answer can wait a few hours
  or days, so the question can serve as the start
  of an educational prescription.

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A patient presentation

• The patients surname.
• The patients age.
• The patients gender.
• When the patient was admitted.
• The chief complaint(s) that led to admission. For
  each complaint, mention the following
• Where in the body it is located.
• Its quality.
• Its quantity, intensity and degree of impairment.

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A patient presentation

1. Its chronology when it began, constant/episodic,
   progressive.
2. Its setting under what circumstances did/does it
   occur.
3. Any aggravating or alleviating factors.
4. Any associated symptoms.
5. Whether a similar complaint had happened
   previously. If so
6. How it was investigated.
7. What the patient was told about its cause.
8. How the patient had been treated for it.

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A patient presentation

1. Pertinent past history of other conditions that
   are either of prognostic significance or would
   affect the evaluation or treatment of the chief
   complaint.
2. And how those other conditions have been treated.
3. Family history, if pertinent to chief complaint
   or hospital care.
4. Social history, if pertinent to chief complaint
   or hospital care.

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A patient presentation

• Their
• (a) Ideas (what they think is wrong with them)
• (b) Concerns (about their illness, and other
  issues)
• (c) Expectations (of whats going to happen to
  and for them).
• Their condition on admission
• (a) acutely and/or chronically ill
• (b) severity
• (c) requesting what sort of help.
• The pertinent physical findings on admission.
• The pertinent diagnostic test results.

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A patient presentation

1. Your concise, one-sentence problem synthesis.
2. What you think the most likely diagnosis is.
3. And the other items in your differential
   diagnosis.
4. Any further diagnostic studies you plan to carry
   out.
5. Your estimate of the patients prognosis.
6. Your treatment plans.

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A patient presentation

1. How you will monitor the treatment.
2. And what you will do if the patient doesnt
   respond to the treatment.
3. The educational prescription you would like to
   write for yourself in order to better understand
   the patients disorder (background knowledge)
   or how to care for the patient (foreground
   knowledge) in order to become a better clinician.

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Self-evaluation Answerable Questions

• Are you asking any questions at all?
• Are you
• Asking 4 part questions?
• Using education prescriptions?
• Asking whats your evidence for that?
• Is your success rate of asking answerable
  questions rising?
• Do your questions compare with those of respected
  colleagues?

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Critically Appraised Topic

• Declarative title
• Question
• Name of paper
• Search terms
• Design
• Setting
• Patients

• Intervention
• Outcome Measures
• Results
• Conclusion
• Commentary

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Summary

• Questions are design specific
• Answerable question, PICO (DOE, POEM)
• Background Vs Foreground questions
• Textbooks are more useful for background Qs
• Broad Vs Narrow Qs
• CAT

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THANK YOU