MAXIMS, RULES, AND GUIDES IN THE MANAGEMENT OF A PATIENT
Reynaldo O. Joson, MD
BASIC MAXIMS
1. Nothing is absolute in medicine.
1.1 There are exceptions to the rules.
1.2 Anything is possible.
1.3 There are more than one way of doing things in medicine.
1.4 There is no such thing as absolutely certain diagnosis, whether it be clinical,
paraclinical, histopathologic, or postmortem diagnosis.
2. The only routine in medicine is a rational decision-making in the management of a patient with a health problem.
2.1 Rational decision-making weighs the probability of being successful in the
achievement of the goals in the management of a patient.
2.2 Rational decision-making relies more on general rules than on the exceptions.
2.3 Rational decision-making banks on the more common rather than on the least
common or rare events.
2.4 Rational decision-making uses processes rather than gut-feel.
2.5 A rational decision-making may not always be correct. As long as the decision-
making is rational, it is acceptable. A rational decision-making is more often
correct than wrong compared to an irrational decision-making.
2.6 A decision-making is deemed correct only after its implementation has resulted in the
achievement of the goals in the management of a patient.
THE DIAGNOSTIC PROCESS AND THE DIAGNOSIS
1. The diagnostic process starts from the time a physician sees the patient up to after treatment.
2. A diagnosis is an identification label of the patient’s health problem.
3. The diagnostic process must be rational for it to be acceptable.
4. A diagnosis that is based on a rational process is not always correct. However, a diagnosis is
more often correct than wrong if it is rationally arrived at.
5. A diagnosis is almost always an educated guess.
INTERVIEW AS A DIAGNOSTIC TOOL
1. Identify the chief complaint or main problem of the patient. Once identified, use it as the
steering wheel in the diagnostic investigation of the patient.
1.1 Inquire on the circumstances associated with the chief complaint.
1.2 Inquire on symptoms. Symptoms are those manifestations perceived by the patient.
1.3 Get clues from the “circumstances and symptoms” to be used in the diagnosis of the
patient.
2. Be effective. Be complete. Be efficient. Be relevant.
3. Know how to get cues from data.
to interpret data.
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4. Know which data to pursue.
to put in the background.
to use in the diagnosis.
not to use in the diagnosis.
PHYSICAL EXAMINATION AS A DIAGNOSTIC TOOL
1. Use the identified chief complaint or main problem of the patient as a guide on what to examine.
1.1 Look for signs. Signs are those manifestations perceived by the physicians.
1.2 Get clues from the signs to be used in the diagnosis of the patient.
2. Be effective. Be accurate. Be complete. Be efficient. Be relevant.
3. Know how to get cues from data.
to interpret data.
4. Know which data to pursue.
to put in the background.
to use in the diagnosis.
not to use in the diagnosis.
INTERVIEW AND PHYSICAL EXAMINATION
1. Interview and physical examination can be done in any order as dictated by the circumstances.
2. Interview and physical examination can be done simultaneously.
3. The goal of interview and physical examination is diagnosis.
4. Correlate data from interview and physical examination to come out with a rational clinical
diagnosis.
5. If there is a question on which data to put more reliance on, choose the “sign” data over
“symptom” data. Remember, however, that for the “sign” data to be reliable, they must
be accurate.
CLINICAL DIAGNOSTIC PROCESS
1. A clinical diagnosis is one that is derived from the interview and physical examination, or put
in another way, it is one that is derived from the symptoms and signs.
2. After the interview and physical examination, the symptoms and signs are analyzed to come
out with a clinical diagnosis. Essentially, two processes are used in coming out with a clinical diagnosis. These two processes are pattern recognition and prevalence.
3. Pattern recognition means the realization that the patient’s presentation conforms to a
previously learned picture or pattern of disease.
4. Prevalence means the choice of a diagnosis is based on the frequency of occurrence of the
disease in a certain locality, in a certain age and sex group, and in the affected organ and
system.
5. Elemental steps in making a diagnosis:
5.1 Identify which organ or tissue or system is involved.
5.2 Then, identify the disease in general terms, such as inflammation, infection, tumor,
trauma, endocrine, etc.
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5.3 Then, try to be more specific in identifying the disease, if possible, such as malignant
neoplasm, abscess, etc.
6. Knowing the nomenclature of diseases facilitates diagnostic labeling.
PARACLINICAL DIAGNOSTIC PROCESS
1. After the clinical diagnosis, the next step to do is to determine whether a paraclinical diagnostic
procedure is needed or not. A paraclinical diagnostic procedure is a diagnostic procedure
that is done after the clinical diagnosis is arrived at and its objective is to make the
diagnosis more definite.
2. To decide whether a paraclinical diagnostic procedure is needed or not, a physician should
consider the following factors:
2.1 How certain he is with the clinical diagnosis.
If he is quite certain or very certain, in general, a paraclinical diagnostic
procedure is not needed. The quite certain clinical diagnosis becomes
automatically the pretreatment diagnosis.
If he is not quite certain or uncertain, in general, a paraclinical diagnostic
procedure is needed.
In general, a clinical diagnosis is said to be quite certain if it is based primarily
on signs that are reinforced by the symptoms and prevalence data.
A clinical diagnosis is said to be uncertain if it is based primarily on symptoms
or on prevalence data.
2.2 Whether a more definite diagnosis is needed or not for some reasons or another.
If the contemplated treatment procedure is mutilating, risky, etc., then a more
definite diagnosis is needed.
If the treatment for the differential diagnosis is the same as that for the primary
clinical diagnosis, then a paraclinical diagnostic procedure may not be
needed. If it is different, then a more definite diagnosis is indicated.
3. Once a decision is made that a paraclinical diagnostic procedure is needed, the next step is to
choose the most cost-effective procedure for the patient by considering the various
factors (tabulate, compare, and analyze):
Procedures Benefit (goal) Risk Cost Availability
Option1
Option2
Option3
4. After the paraclinical diagnostic procedure has been done, the next step is to interpret the
result. The result of the paraclinical diagnostic procedure must be correlated with the
signs and symptoms of the patient to come out with a pretreatment diagnosis.
SELECTION OF TREATMENT
1. Selection of treatment procedure is based primarily on the pretreatment diagnosis.
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2. Select the most cost-effective treatment for the patient after considering the various factors
(tabulate compare, and analyze):
Treatment Benefit (goal) Risk Cost Availability
Option1
Option2
Option3
3. The final decision on the type of treatment to institute will rest on the patient.
4. Know when and to whom to refer.
ADVICE AND INFORMED CONSENT
1. After the interview and physical examination and after the physician has arrived to a clinical
diagnosis, the next step is to advice the patient on the nature of his health problem.
2. After the clinical diagnosis has been explained to the patient and/or his relatives, the next step
is to advice whether a paraclinical diagnostic procedure is needed or not. If a paraclinical
diagnostic procedure is needed, the patient is informed of the various options. He is
advised on the most cost-effective option. Performing the paraclinical diagnostic
procedure can only be carried out after the physician has secured an informed consent
from the patient.
3. After the paraclinical diagnostic procedure has been performed, the next step is to advice the
patient on the results.
4. After a pretreatment diagnosis has been gotten, the next step is to inform the patient on the
various options of treatment. He is advised on the most cost-effective treatment option.
Carrying out the treatment procedure can be done only after the physician has secured an
informed consent from the patient.
5. After treatment, the patient should be advised on the results and subsequent management,
specifically follow-up. The patient should also be given advice on health maintenance.
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ADVISING PATIENTS AND RELATIVES
A physician deals with both patients and their relatives or guardians.
A successful physician-patient-relative relationship is based on the establishment and maintenance of good rapport initiated and accomplished by the physician. A good rapport basically emanates from the trust and confidence given by the patient-relative to the physician. This trust and confidence can be gained by the physician through many ways. The following are some qualities of the physician that will promote trust and confidence of the patient-relative:
Competent physician
Honest
Gentle
Compassion and shows concern
Courteous
Patient, persevering, and understanding
Advising a patient and his relatives is a major pathway through which a rapport can be established and maintained by the physician.
In managing a patient, advising is usually needed on:
1. clinical diagnosis
2. need for a paraclinical diagnostic procedure
3. nature of a paraclinical diagnostic procedure
4. results of a paraclinical diagnostic procedure
5. plan of treatment
6. outcome of treatment
7. prognosis of the disease
8. maintenance of health after treatment
Advising a patient and his relatives on any matter can make or break the physician-patient-relative relationship. Thus, it is important that the physician knows how to advise.
The following are tips in advising:
1. Always include the relatives of the patient in the advising, if they are available.
2. Assess the psychological make-up, the health beliefs, and the level of
competency of the patient and the relatives before making any advise.
Make strategies that will promote rapport.
2.1 Be honest but not brutally frank.
For example, slowly divulge the diagnosis of an
incurable disease or a frightening disease.
2.2 Use terminologies or explanations that can be easily
understood by the patient and his relatives.
3. Use all kinds of strategies that will make the patient and his relatives like you.
4. Explain to the patient and relatives the processes you use in arriving to a
diagnosis, recommendation for a paraclinical diagnostic procedures and
treatment.
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KNOWING WHEN AND TO WHOM TO REFER
There will always be patients whose health problems will be beyond a physician’s existing competencies.
Such patients may have a very unusual health problem whose diagnosis is extremely difficult.
Such patients may have usual health problems but whose treatment is beyond a physician’s existing competencies (example - a primary health care physician who has not been trained to do a surgical operation).
Whether a person is still in medical school or has graduated, there will always be patients whose health problems are beyond his present existing competencies.
When to refer?
All physicians, both certified and not yet certified, must know their limitations. Only they themselves can determine their own limitations. They must realize their limitations so that they do not cause undue harm to their patients and so that they know when to refer to colleagues.
Refer means asking for help from and conferring with colleagues. Referring a patient to a colleague may mean totally transferring the care of a patient to him or continuing to manage the patient with his help. A proper communication either oral or written is in order.
To whom to refer?
Referral must be made to somebody
who may or can solve the patient’s health problem
rationally, effectively, efficiently, and humanely, and
who has a good track record of handling the kind of problem on hand.
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Written in 1998
Part of Management of a Surgical Patient