1 / 90

4 Steps to Clinical Problem Solving

A Logical Approach to Clinical Problem Solving & An applied example on Urinary Incontinence. 4 Steps to Clinical Problem Solving. Making the Diagnosis Assessing the severity and/ or stage of the disease Rendering a treatment based on the stage of the disease

eladiac
Download Presentation

4 Steps to Clinical Problem Solving

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. A Logical Approach to Clinical Problem Solving& An applied example on Urinary Incontinence

  2. 4 Steps to Clinical Problem Solving • Making the Diagnosis • Assessing the severity and/ or stage of the disease • Rendering a treatment based on the stage of the disease • Following the patient response to treatment

  3. Involving in many instances: • GIGO • Putting the pieces of the puzzle in their right place Making the diagnosis • Careful evaluation of the gathered data: • History • Investigations • Making a short list of Differential Diagnosis

  4. Assessing the severity and / or stage of the Disease • Determining how bad the disease is • Sometimes there is no ‘mild or severe’ yet the disease may be in itself a risk for another condition: • Bacterial vaginosis

  5. Treating based on the stage • PET at 32 weeks gestation • Mild • Severe • Urinary Tract Infection • Lower urinary tract • Upper urinary tract

  6. Following the response to treatment / expectant management • Based on clinical judgment • Based on laboratory testing • Based on imaging techniques.

  7. However when you are solving a case on paper, it is a bit different… • 7 questions need to be answered • What is the most likely diagnosis? • What should be your next step? • What is the most likely mechanism for this process? • What are the risk factors for this condition? • What are the grade / severity and possible complications of this disease process? • What is the best therapy? Is there an alternative therapy (ies)? • How would you confirm the diagnosis

  8. What is the most likely diagnosis? • Means : The most common cause • Data presented may be confirming the diagnosis • Or they may be leading to another cause

  9. What should be your next step? • Depends on how much information is provided: • If enough: you will make the diagnosis Stage the disease and treat accordingly • No enough information More diagnostic tests • If he is providing treatment then the next step will be to follow the response

  10. What is the likely mechanism for this process? • The pathophysiology of the disease itself • The disease may lead to another or to a complication • What are the risk factors for this disease process? • Are they present in the context • Do they mandate further testing / investigations. • What is the best therapy? • Do NOT jump to treatment on intuition • The treatment should be tailored according to: • Stage/ severity of the disease • The best possible alternative according to the patient characteristics • How would you confirm the diagnosis? • Making the point and concluding the story

  11. A 48-year old G3 P3+0 woman complains of a 2-year history of loss of urine 4-5 times each day, typically occurring 2-3 seconds after coughing, lifting or sneezing, additionally, she notes dysuria and an urge to void during these episodes. These events causes her embarrassment and interferes with her daily activities. She is otherwise in good health. • A urine culture 1 month ago was negative. • On examination, • she is slightly obese, the BP is 130/80 and the HR is 80bpm and regular with a temp of 37˚C, her breast examination is normal and so were her abdominal examination. • A midstream urinalysis is unremarkable. What is your next step? What is the most likely Diagnosis? What is the best initial treatment?

  12. Bladder Control Problems • Problems of: • Bladder Emptying • Bladder Storage

  13. Bladder Emptying Problems • Urinary Retention • Obstruction from within • Obstruction from outside • Stretch attenuation of the urethra • Bladder neck obstruction • Angulation of the urethra • Neurogenic causes [reflex from pain, retention with overflow] Image source: Virginia Urology Center

  14. Urinary Incontinence Definition: Urinary incontinence is uncontrolled leakage of urine causing hygienic and social problems.

  15. Urinary Incontinence is Common Among Older Adults 18 Men Women 16 14 12 10 Percentage of respondents in each age group 8 6 4 2 0 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 >85 Age (years)

  16. Bladder Storage Problems • Overactive Bladder • Stress Incontinence • Mixed Incontinence • Overflow Incontinence • Fistulas

  17. Overactive Bladder Urgency Frequency Urge incontinence OVERACTIVE BLADDER

  18. Stress Incontinence Stress incontinence occurs when a small amount of urine escapes while the person coughs, sneezes, laughs, jumps or lifts something heavy.

  19. Stress Incontinence (b) Woman with stress incontinence (a) Continent woman External urethral sphincter Sudden increase in intra-abdominal pressure

  20. Overflow Incontinence Overflow incontinence happens when urine leaks from an overfilled bladder.

  21. Overflow Incontinence

  22. Mixed Incontinence Mixed incontinence occurs when a person has both the symptoms of urge incontinence and stress incontinence.

  23. Mixed Incontinence Sudden increase in intra-abdominal pressure Uninhibited detrusor contractions

  24. Prevalence • 8-51% in community • At least 50% in nursing homes • 25% suffer from severe incontinence • Greatest in older women and increases with age • Incontinence 6-10x greater in women than in men

  25. Impact on quality of life • Significant worldwide health problem • Affects 16 million women in US • Cost of diagnosing and managing UI exceed $26 billion annually in US • Adult diaper sales $5-6 billion/yr • Great social impact as well • Leaking depression stop exercise gain weight and so on ….

  26. Approach • Every woman is different • Consider quality of life from the patient’s point of view • History • Voiding diary • Quality of life assessment

  27. Normal Bladder Function • Functional urethra is intra-abdominal • Increased abdominal pressure transmitted equally to bladder and urethra • With increased stress urethro-vesical junction responds to stress by closing tight • Bladder is a voluntary smooth muscle • Inherent ability to maintain low pressure with filling-increase in volume:compliance

  28. Bladder Pressure-Volume Relationship

  29. Anatomy of Micturition • Detrusor muscle • External and Internal sphincter • Normal capacity 300-600cc • First urge to void 150-300cc • CNS control • Pons - facilitates • Cerebral cortex - inhibits • Hormonal effects - estrogen

  30. Interpretation of Post-Void Residual • PVR < 50cc - Adequate bladder emptying • PVR > 150cc - Avoid bladder relaxing drugs • PVR > 200cc - Refer to Urology • PVR > 400cc - Overflow UI likely

  31. Peripheral Nerves in Micturition • Parasympathetic (cholinergic) - Bladder contraction • Sympathetic - Bladder Relaxation • Bladder Relaxation (β adrenergic) • Sympathetic - Bladder neck and urethral contraction (α adrenergic) • Somatic (Pudendal nerve) - contraction pelvic floor musculature

  32. Peripheral Nerves in Micturition

  33. Factors Associated with Bladder Control Problems • Age • Childbirth • Gender • Menopausal Status • Surgery • Lifestyle • Medications • Concomitant illnesses

  34. Potentially Reversible Causes D - Delirium I - Infection A - Atrophic vaginitis or urethritis P - Pharmaceuticals P - Psychological disorders E - Endocrine disorders R - Restricted mobility S - Stool impaction 2

  35. Medications That May Cause Incontinence • Diuretics • Anticholinergics - antihistamines, antipsychotics, antidepressants • Seditives/hypnotics • Alcohol • Narcotics • α-adrenergic agonists/antagonists • Calcium channel blockers

  36. 10 Warning Symptoms of Bladder Control Problems #1 Any leakage of urine

  37. 10 Warning Signs of Bladder Control Problems #2 Leakage of urine, regardless of amount, on coughing, sneezing, laughing or standing.

  38. 10 Warning Signs of Bladder Control Problems #3 Leaking urine on the wayto thetoilet.

  39. 10 Warning Signs of Bladder Control Problems #4 Bed wetting at any age over six years.

  40. 10 Warning Signs of Bladder Control Problems #5 An urgent need to pass urine, being unable to hold on.

  41. 10 Warning Signs of Bladder Control Problems #6 Passing urine more frequently than 8 times a day and only passing small amounts.

  42. 10 Warning Signs of Bladder Control Problems #7 Blood in the urine.

  43. 10 Warning Signs of Bladder Control Problems #8 Inability to urinate (retention of urine).

  44. 10 Warning Signs of Bladder Control Problems #9 Pain when passing urine.

  45. 10 Warning Signs of Bladder Control Problems #10 Progressive weakness of the urinary stream or a stream that stops and starts instead of flowing out smoothly. Image source: Malaysian Urological Association

More Related