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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3230_Библиотеки_им_академика_М_И_Перельмана
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IMPORTANT QUESTIONS AND ANSWERS
xviii
If we took the pile of 77 records from the study, we could simulate
repeat studies by selecting a set of notes at random from the pile, exam-
ining it, returning it, and doing this 77 times. If a large number of such
simulated studies were done, then from the binomial distribution there
would be a 99.7% chance of finding nephropathy in 0/77 or 1/77 or 2/77
or 3/77 or 4/77 of patients with a controlled BP in different simulated
studies (i.e., from 0% [0/77] to 5.2% [4/77]). There is thus a 99.7% chance
of replicating the finding of 1/77 by a repeat result being between 0/77
and 4/77 inclusive.
By comparison, the standard 95% confidence interval for 1/77 is 0.03%
to 7.02% and the 99% confidence interval for 1/77 is 0.01% to 9.37%.
However, the probability of replication between two limits is more simi-
lar to the percentage confidence interval if the numbers in the study are
high and the observed result is near to 50%.
A fact is an account of an observation, but an opinion is a prediction
about something that has not yet (or even cannot) be seen. If an opinion
can be checked by observation, it can be founded on evidence (it is
substantiable). If it can never be observed, it cannot be founded on evi-
dence (it is unsubstantiable). An opinion can thus be substantiated if it
can be based on past evidence.
For example, if an individual patient’s AER is between 20 and 40
μg/minute, then an opinion that such a diabetic patient with a controlled
BP is unlikely to develop nephropathy would be well founded or substan-
tiated by the fact that of 77 such past patients, only 1 went on to get
nephropathy in a particular study.
14. How do these ideas relate to
statistical and other models of
diagnosis?
Statistical and other mathematical methods (many based on Bayes theorem)
generate a value much like a diagnostic test. These may be calculated
estimates of some biological value, e.g., a calculated glomerular filtration
rate, a diagnostic score, or an estimated probability. All these numerical
outputs of a calculation can be treated in the same way as direct meas-
urements by calibrating them against the frequency of some outcome
(e.g., the proportion who progress to requiring dialysis within 2 years—
see Fig. 2.3). The numerical outputs could then be incorporated into the
suggestive or confirmatory evidence for the diagnosis.
1. Llewelyn DEH, Garcia-Puig J (2004). How different urinary albumin excretion rates can predict
progression to nephropathy and the effect of treatment in hypertensive diabetics. J Renin Angio-
tensin Aldosteron e Syst 5;141–145.
IMPORTANT QUESTIONS AND ANSWERS
xix
Decision analysis
1,2
is essentially a process that estimates the result of a
detailed therapeutic clinical trial on a hypothetical group of patients in a
transparent way when a real detailed trial is not available or impractica-
ble. The analysis is usually applied to an individual patient who thus is
identical to all those in the hypothetical group. The approach uses available
estimates of outcome frequencies in the medical literature from related
studies and also estimates from the patient of the range of personal
well-being that should be gained from each outcome.
The analysis involves calculating the average degree of well-being for
each treatment outcome in a transparent way. Doctors may do this for
an individual patient by estimating the outcome of such a hypothetical
trial without making calculations. This approach is not covered in this book.
Detailed contents
1. Dowie J, Elstein A (1988). Professional judgement. A reader in clinical decision making.
Cambridge, UK: Cambridge University Press.
2. Llewelyn H, Hopkins A (1993). Analysing how we reach clinical decisions. London: Royal College
of Physicians of London.
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xxi
Symbols and abbreviations
± with/without
l imply
i increased
d decreased
° degrees
> greater than
< less than
5-HIAA 5-hydroxyindole acetic acid
Ab antibody
ABG(s) arterial blood gas(es)
ACE angiotensin-converting enzyme
ACTH adrenocorticotrophic hormone
ADH antidiuretic hormone
AER albumin excretion rate
AFB acid-fast bacillus
ALS amyotrophic lateral sclerosis
ALT alanine transaminase
AML acute myeloid leukemia
ANA anti-nuclear antibody
ANCA anti-neutrophil cytoplasmic antibody
A-P anterior to posterior
ARDS acute respiratory distress syndrome
AS
aortic stenosis
ASOT
anti-streptolysin O titer
AST
asparate transaminase
AV
atrioventricular
AXR
abdominal X-ray
B-hCG
B-human chorionic gonadotrophin
BM
bone marrow
BMI
body mass index
BP
blood pressure
bpm beats per minute
BUN blood urea nitrogen
cANCA cytoplasmic anti-neutrophil cytoplasmic antibody
CAPD
CBC
continuous ambulatory peritoneal dialysis
complete blood count
CC
chief complaint
CFS
chronic fatigue syndrome
CHF
congestive heart failure
SYMBOLS AND ABBREVIATIONS
xxii
CIN
cervical intraepithelial neoplasia
CK-MB
creatine kinase
MB isoenzyme
CLL
chronic lymphocytic leukemia
CML
chronic myeloid leukemia
CNS
central nervous system
COPD
chronic obstructive pulmonary disease
CPK
creatine phosphokinase
CRF
chronic renal failure
CRP
C-reactive protein
CSF
cerebrospinal fluid
CT
computerized tomography
CTPA
computerized tomographic pulmonary angiogram
CV
cardiovascular
CVA
cerebrovascular accident; costovertebral angle
CVP
central venous pressure
CVS
cardiovascular system
CXR chest X-ray
DC direct current
D-dimer dextrorotatory dimer
DH drug history
DIC disseminated intravascular coagulation
DIP distal interphalangeal (joint)
dL deciliter
DL
CO
carbon monoxide diffusing capacity
DM diabetes mellitus
DOB date of birth
DVT deep vein thrombosis
ECG (EKG) electrocardiogram
ECT electroconvulsive therapy
EEG electroencephalogram
EF ejection fraction
EGD esophagogastroduodenoscopy
ELISA enzyme-linked immunosorbent assay
EMG electromyography
ENT ear, nose, throat
ERCP endoscopic retrograde cholangiopancreatography
ESR erythrocyte sedimentation rate
FDP(s) fibrogen degredation product/s
FEV
1
forced expiratory volume (1 second)
FH family history
FiO
2
fraction of inspiried oxygen
Fl fluorescein
FSH follicular stimulating hormone
FT3 free T3
FT4 free T4
SYMBOLS AND ABBREVIATIONS
xxiii
FUO fever of unknown origin
FVC forced vital capacity
G6PD glucose-6-phosphate dehydrogenase
GALS gait, arms, legs, spine
γGTP γ glutamyl transpeptidase
GBM glomerular basement membrane
GCS Glasgow Coma Scale
GH growth hormone
GI gastrointestinal
GP general practitioner
G/g gram
G/dL grams/deciliter
GTT glucose tolerance test
GU genitourinary
Hb hemoglobin
HBsAG hepatitis B surface antigen
hCG human chorionic gonadotrophin
HCV hepatitis C virus
Hg mercury
HIV human immunodeficiency virus
HLA-B27 human lymphocyte antigen B27
HPI history of present(ing) illness
HR heart rate
HR-CT high resolution computerized tomography
HSV herpes simplex virus
HUS hemolytic uremic syndrome
IGF insulin-like growth factor
IgM immunoglobin M
IHD ischemic heart disease
IM intramuscular
IP interphalangeal (joint)
IUD intrauterine contraceptive device
IV intravenous
IVC inferior vena cava
JVP jugular venous pressure
K potassium
L liter
LDH lactate dehydrogenase
LFT liver function test
LH luteinizing hormone
LIF left iliac fossa
LMN lower motor neuron
LN lymph node
LP lumbar puncture
LV left ventricle (or ventricular)
LVF left ventricular failure
LVH left ventricular hypertrophy
SYMBOLS AND ABBREVIATIONS
xxiv
MCHC mean corpuscular hemoglobin concentration
MCHC mean corpuscular hemoglobin concentration
MCP metacarpophalangeal (joint)
MCV mean corpuscular volume
MI myocardial infarction
mmHg millimeters of mercury
mmol millimoles
MP metatarsophalngeal (joint)
MRA magnetic resonance angiogram
MRCP magnetic resonance cholangiopancreatography
MRI magnetic resonance imaging
MS multiple sclerosis
MSU mid-stream urine
Na sodium
NSAIDs nonsteroidal anti-inflammatory drugs
NSAP nonspecific abdominal pain
OAHCD Oxford American Handbook of Clinical Diagnosis
P2 pulmonary component of second heart sound
P-A posterior to anterior
PA pernicious anemia
PaO
2
arterial oxygen tension
PAS periodic acid Schiff
PCO
2
carbon dioxide tension
PCP Pneumocystis pneumonia
PCR polymerase chain reaction
PCWP pulmonary capillary wedge pressure
PE pulmonary embolism
PEFR peak expiratory flow rate
PFK phosphofructokinase
PFT pulmonary function test
PIP proximal interphalangeal (joint)
PMH past medical history
PND paroxysmal nocturnal dyspnea
po per os (by mouth)
PR per rectum (by the rectum)
PSA prostate-specific antigen
PT prothrombin time
PTT partial thromboplastin time
PUO pyrexia of unknown origin
qd quaque die (once daily)
qid quater in die (four times daily)
RA right atrium (or atrial)
RBB right bundle branch
RHF right-sided heart failure
RIF right iliac fossa
RLQ right lower quadrant
RS respiratory system
SYMBOLS AND ABBREVIATIONS
xxv
RUQ right upper quadrant
RV right ventricle (or ventricular)
SBE subacute bacterial endocarditis
SH social history
SHBG sex hormone-binding globulin
SLE systemic lupus erythematosus
STEMI ST-elevation myocardial infarction
SVC superior vena cava
SVT supraventricular tachycardia
TB tuberculosis
TFT thyroid function test
tid three times a day
TSH thyroid-stimulating hormone
TURP transurethral resection of the prostate
UMN upper motor neuron
URI upper respiratory infection
URTI upper respiratory tract infection
UTI urinary tract infection
VGCC voltage-gated calcium channel
VSD ventricular septal defect
WBC white blood cell (count)
WHO World Health Organization
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Chapter 1
1
The diagnostic process
Introduction 2
Developing a differential diagnosis 3
Problem-solving skills 4
Dynamic diagnoses and the possibility
of cognitive error 12
Summary 14
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