Advanced Assessment: Interpreting Findings and

Formulating Differential Diagnoses

Visit the link below to download the full version of this book:
https://cheaptodownload.com/product/advanced-assessment-interpreting-findings-an
d-formulating-differential-diagnoses-third-edition-full-pdf-docx-download/
4363_FM_i-xiv 15/10/14 9:50 PM Page ii

Great nursing care begins with great resources...

now and throughout your career!
Fitzgerald
Nurse Practitioner
Essential
Certification Pocket
Examination and
Practice Preparation
References
Winland-Brown & Dunphy
McCaffrey & Youngkin
Adult-Gerontology and NP NOTES
Family Nurse Practitioner Nurse Practitioner’s
Certification Examination Clinical Pocket Guide
Review Questions and Strategies
Pedersen
Colyar PSYCH NOTES
Advanced Practice Clinical Pocket Guide
Nursing Procedures
Iannuzzi-Sucich & Sanoski
Kennedy-Malone HERBAL NOTES
Advanced Practice Nursing Complementary &
Alternative Medicine
in the Care of Older Adults Pocket Guide
Vallerand & Sanoski
Jones
Davis’s Drug Guide for Nurses POCKET ANATOMY
& PHYSIOLOGY

Buy YOURs TODAY!

www.fadavis.com
4363_FM_i-xiv 15/10/14 9:50 PM Page iii

Advanced
Assessment
Interpreting Findings
and Formulating
Differential Diagnoses
THIRD EDITION

Mary Jo Goolsby, EdD, MSN, ANP-C, CAE, FAANP

Principal
Institute for Nurse Practitioner Excellence
Augusta, Georgia

Laurie Grubbs, PhD, MSN, ANP-C

Professor, Associate Dean for Academic Affair
Florida State University
College of Nursing
Tallahassee, Florida
4363_FM_i-xiv 15/10/14 9:50 PM Page iv

F. A. Davis Company
1915 Arch Street
Philadelphia, PA 19103
www.fadavis.com

Copyright © 2015 by F. A. Davis Company

Copyright © 2015 by F. A. Davis Company. All rights reserved. This book is protected by
copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any
form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without
written permission from the publisher.

Printed in the United States of America

Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1

Publisher, Nursing: Joanne Patzek DaCunha, RN, MSN

Developmental Editor: Amy Reeve
Director of Content Development: Darlene D. Pedersen
Content Project Manager: Echo Gerhart
Electronic Project Editor: Sandra Glennie
Design Manager: Carolyn O’Brien

As new scientific information becomes available through basic and clinical research,
recommended treatments and drug therapies undergo changes. The author(s) and publisher have
done everything possible to make this book accurate, up to date, and in accord with accepted
standards at the time of publication. The author(s), editors, and publisher are not responsible for
errors or omissions or for consequences from application of the book, and make no warranty,
expressed or implied, in regard to the contents of the book. Any practice described in this book
should be applied by the reader in accordance with professional standards of care used in regard
to the unique circumstances that may apply in each situation. The reader is advised always to
check product information (package inserts) for changes and new information regarding dose
and contraindications before administering any drug. Caution is especially urged when using
new or infrequently ordered drugs.

Library of Congress Cataloging-in-Publication Data

Advanced assessment : interpreting findings and formulating differential diagnoses / [edited by]
Mary Jo Goolsby, Laurie Grubbs. — Third edition.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-8036-4363-5 — ISBN 0-8036-4363-2
I. Goolsby, Mary Jo, editor. II. Grubbs, Laurie, 1951- editor.
[DNLM: 1. Nursing Assessment—methods. 2. Diagnosis, Differential. 3. Nurse Practitioners.
WY 100.4]
RC71.5
616.07´5—dc23
2014015703

Authorization to photocopy items for internal or personal use, or the internal or personal use of
specific clients, is granted by F. A. Davis Company for users registered with the Copyright
Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.25 per copy
is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that
have been granted a photocopy license by CCC, a separate system of payment has been arranged.
The fee code for users of the Transactional Reporting Service is: 8036-4363-2/15 0 + $.25.
4363_FM_i-xiv 15/10/14 9:50 PM Page v

Preface
T he idea for this book evolved over several years, while teaching an advanced
health assessment course designed primarily for nurse practitioner (NP)
students. Although many health assessment texts were available, they lacked an
essential component—the information needed to arrive at a reasonably narrow
differential diagnosis when a patient presented with one of the almost endless
possible complaints. The response to the earlier editions of this text supported
our idea. We hope that this updated edition will continue to help advanced prac-
tice students, new practitioners, and experienced practitioners faced with new
presentations.
As NPs increasingly become the providers of choice for individuals seeking pri-
mary and specialty care, the need for expertise in the assessment and diagnostic
processes remains fundamental. In spite of the growth in available technology and
diagnostic studies, performing assessment skills correctly, obtaining valid data, and
interpreting the findings accurately are essential for the safe, high-quality, patient-
centered, and cost-effective practice for which NPs are known.
Even once these skills are accomplished, accurate diagnosis remains a difficult
aspect of practice. However, it was our experience that students and practicing
clinicians rarely referred to their health assessment book after completing their
assessment course. Instead, they tended to turn to clinical management texts,
which focus on what to do once the diagnosis is known. This supported our belief
that while assessment texts cover common findings for a limited range of disor-
ders, most are not perceived as helpful in guiding the diagnostic process. Novice
practitioners often spend much energy and time narrowing their differential di-
agnosis when they have no clear guidance that is driven by the patient or com-
plaint. For this reason, our aim was to develop a guide in the assessment and
diagnostic process that is broad in content and suitable for use in varied settings.
Advanced Assessment: Interpreting Findings and Formulating Differential Diag-
noses has been designed to serve as both a textbook during advanced health
assessment course work and as a quick reference for practicing clinicians. We be-
lieve that studying the text will help students develop proficiency in performing
and interpreting assessments, recognizing the range of conditions that can be in-
dicated by specific findings. Once in practice, we believe that the text will aid
individualized assessment and narrowing of differential diagnosis.
The book consists of three parts. Part 1 provides a summary discussion of as-
sessment and some matters related to clinical decision-making. In addition to
discussing the behaviors involved in arriving at a definitive diagnosis, each chapter
covers some pitfalls that clinicians often experience and the types of evidence-
based resources that are available to assist in the diagnostic process. This section
v
4363_FM_i-xiv 15/10/14 9:50 PM Page vi

vi Preface

includes a unique chapter on conducting a genetic assessment. This component

of health assessment has great potential, with recent advances in the information
and technology related to genetics and genomics. It is critical that clinicians be
able to address the potential of hereditary diseases and genetic variations that
may affect their patients. This chapter, like the one on clinical decision-making,
is relevant to the content of all subsequent chapters.
Part 2 serves as the core of the book and addresses assessment and diagnosis
using a system and body region approach. Each chapter in this part begins with
an overview of the comprehensive history and physical examination of a specific
system, as well as a discussion of common diagnostic studies. The remainder of
the chapter is then categorized by chief complaints commonly associated with
that system. For each complaint, there is a description of the focused assessment
relative to that complaint, followed by a list of the conditions that should be con-
sidered in the differential diagnosis, along with the symptoms, signs, or diagnostic
findings that would support each condition.
Part 2 also includes an extensive color atlas, which contains color photographs
for several chapters. Figures within chapters are provided to better depict exam-
ination techniques or expected findings. With each edition, additional complaints
and conditions have been included in several differential diagnosis sections.
Finally, Part 3 addresses the assessment and diagnosis of specific populations:
those at either extreme of age (young and old) and pregnant women. This part
places a heavy emphasis on the assessments that allow clinicians to evaluate the
special needs of individuals in these populations, such as growth and development
in children and functionality in older patients.
To aid the reader, we have tried to follow a consistent format in the presenta-
tion of content so that information can be readily located. This format is admit-
tedly grounded on the sequence we have found successful as we presented this
content to our students. However, we have a great appreciation for the expertise
of the contributors in this edited work, and some of the content they recom-
mended could not consistently fit our “formula.” We hope that the organization
of this text will be helpful to all readers.
4363_FM_i-xiv 15/10/14 9:50 PM Page vii

Acknowledgments
W e want to express our sincere appreciation for the support and assistance
provided by so many in the development of this book. Their contribu-
tions have made the work much richer.
Particular mention goes to all at F. A. Davis for their enthusiasm, support, and
patience during the process. Most specifically, we acknowledge the invaluable
assistance of Joanne DaCunha, our publisher. Joanne’s continued belief in the
concept and in our ability to develop the content was a vital factor in our work,
and she was always available to guide us throughout the process. We also want
to express our gratitude to our project manager, Marsha Hall and our project
editor, Echo Gerhart, for coordinating so many tasks and keeping us on track,
and to Amy Reeve for her careful editorial assistance.
We are immensely grateful to the contributors of this edition, who shared their
expertise and knowledge to enhance the content. They were a pleasure to work
with. We also acknowledge those who provided content to an earlier edition:
Saundra Turner, Randolph Rasch, Karen Koozer-Olson, Diane Mueller, Phillip
Rupp, and Patricia Hentz. In addition to the contributors, we also want to thank
the many reviewers of this and previous editions for their timely and thoughtful
feedback. For this edition, we thank Dr. Margaret Bobonich for her review and
suggestions for Chapter 3, Skin Assessment.
Personal acknowledgments from Laurie Grubbs
Most of all, I would like to thank my friend and coauthor, Mary Jo, for providing
the impetus to write this book—an often talked about aspiration that became a
reality—and to F. A. Davis for their enthusiasm, support, and patience during
the process.
I would also like to thank my children, Jennifer and Ashley, for their support
and for being themselves—intelligent, talented, beautiful daughters.
Personal acknowledgments from Mary Jo Goolsby
I must also express thanks to my dear friend and colleague, Laurie. During much
of my time in academia, I have had the pleasure and honor of co-teaching with
Laurie, from whom I learned so much.
Above all else, I also thank my husband, H. G. Goolsby. He continues to offer
constant support and encouragement, without which this and other professional
achievements would not be possible.

vii
4363_FM_i-xiv 15/10/14 9:50 PM Page viii

Keep
calm
and

carry

Carry Taber’s today and save 20%

Use promo code: CARRYTABERS

www.Tabers.com www.FADavis.com
4363_FM_i-xiv 15/10/14 9:50 PM Page ix

Contributors
Sara F. Barber, MSN, ANP Catherine “Casey” Jones, PhD, RN,
Professional Park Pediatrics ANP-C, AE-C
Tallahassee, Florida Nurse Practitioner
Texas Pulmonary and Critical Care Associates,
Deborah Blackwell, PhD, WHNP, P.A.
RNC-OB, CNE Bedford, Texas
Dean
Carolinas College of Health Sciences—School Michelle Lajiness, APRN, FNP-BC
of Nursing and Mercy School of Nursing Urology Associates
Charlotte, North Carolina Beaumont Hospital
Royal Oak, Michigan
James Blackwell, MS, ANP-BC
Nurse Practitioner Ann Maradiegue, PhD, RN, FNP-BC,
Department of Internal Medicine FAANP
Carolinas HealthCare System Assistant Professor, School of Nursing
Charlotte, North Carolina and Health Professions
Trinity Washington University,
Leslie L. Davis, PhD, RN, ANP-BC, Washington, DC
FAANP, FAHA
Assistant Professor of Nursing Charon A. Pierson, PhD, GNP, FAANP,
University of North Carolina, Greensboro FAAN
Clinical Assistant Professor of Medicine Editor-in-Chief, Journal of the American
University of North Carolina, Chapel Hill Association of Nurse Practitioners
Consultant, Geriatric Nursing Program
Quannetta T. Edwards, PhD, FNP-BC, Development and Evaluation
WHNP-BC, FAANP Gilbert, Arizona
Professor
College of Graduate Nursing Susanne Quallich, MSN, ANP-BC, NP-C,
Western University of Health Sciences CUNP, FAANP
Pomona, California Nurse Practitioner, Division of Andrology
and Microsurgery
Valerie A. Hart, EdD, APRN, Michigan Urology Center
PMHCNS-BC University of Michigan Health System
Professor of Nursing Ann Arbor, Michigan
Psychotherapist
College of Science, Technology & Health
University of Southern Maine
Portland, Maine

ix
4363_FM_i-xiv 15/10/14 9:50 PM Page x

x Contributors

Diane Seibert, PhD, RN, ANP, Joellen Wynne, MSN, FNP-BC, FAANP
WHNP-BC, FAANP Principal Partner
Assistant Associate Professor, Program Institute for Nurse Practitioner Excellence
Director Family Nurse Practitioner Austin, Texas
Program
Graduate School of Nursing
Uniformed Services University of the Health
Sciences
Bethesda, Maryland
4363_FM_i-xiv 15/10/14 9:50 PM Page xi

Reviewers
Margaret Rose Benz, MSN(R), APRN, Mary McCurry, PhD, RNBC, ANP,
ANP-BC ACNP
Assistant Professor of Nursing DNP Graduate Program Director/Associate
Saint Louis University School of Nursing Professor
St. Louis, Missouri UMASS-Dartmouth
North Dartmouth, Massachusetts
Julie Brandy, RN, PhD, FNP-BC
Assistant Professor Susan Porterfield, PhD, FNP-C
Valparaiso University Director of Graduate Program/Family Nurse
Valparaiso, Indiana Practitioner Coordinator/Assistant
Professor
Noreen E. Chikotas, D.Ed., CRNP Florida State University
Professor, Graduate Program Coordinator, Tallahassee, Florida
Director of Nurse Practitioner Programs
Bloomsburg University Cheryl Swayne, MN, FNP, CS
Bloomsburg, Pennsylvania Associate Professor
Department of Advanced Nursing Studies
Greta Kostac, DNP, FNP-C Northern Kentucky University
Associate Professor Highland Heights, Kentucky
Marian University
Fond du Lac, Wisconsin Teresa Whited, MS, APRN-CNP,
CPNP-PC
Judy M. Kreye, PhD, RN Instructor and Coordinator of the Pediatric
Director of Clinical Education/Assistant Nurse Practitioner Track
Professor University of Oklahoma College of Nursing
Walsh University Oklahoma City, Oklahoma
North Canton, Ohio
Barbara Wilder, DSN, CRNP
Carol T. LePage, PhD, ARNP Professor
Assistant Professor Auburn University School of Nursing
Barry University Auburn, Alabama
Miami, Florida

xi
4363_FM_i-xiv 15/10/14 9:50 PM Page xii
4363_FM_i-xiv 15/10/14 9:50 PM Page xiii

Contents
PART I The Art of Assessment and Clinical Decision-Making
Chapter 1. Assessment and Clinical Decision-Making:
An Overview 2
Chapter 2. Genomic Assessment: Interpreting Findings
and Formulating Differential Diagnoses 12
PART II Advanced Assessment and Differential Diagnosis by
Body Regions and Systems
Chapter 3. Skin 50
Chapter 4. Head, Face, and Neck 76
Chapter 5. The Eye 96
Chapter 6. Ear, Nose, Mouth, and Throat 123
Chapter 7. Cardiac and Peripheral Vascular Systems 163
Chapter 8. Respiratory System 206
Chapter 9. Breasts 226
Chapter 10. Abdomen 244
Chapter 11. Genitourinary System 294
Chapter 12. Male Reproductive System 331
Chapter 13. Female Reproductive System 365
Chapter 14. Musculoskeletal System 403
Chapter 15. Neurological System 443
Chapter 16. Nonspecific Complaints 470
Chapter 17. Psychiatric Mental Health 493
PART III Assessment and Differential Diagnosis in
Special Patient Populations
Chapter 18. Pediatric Patients 526
Chapter 19. Pregnant Patients 563
Chapter 20. Older Patients 592

xiii
4363_FM_i-xiv 15/10/14 9:50 PM Page xiv
4363_Ch01_001-011 03/10/14 11:51 AM Page 1

PART

I
The Art of
Assessment and
Clinical Decision-Making
4363_Ch01_001-011 03/10/14 11:51 AM Page 2

Chapter 1

Assessment and Clinical

Decision-Making: An Overview
Mary Jo Goolsby
Laurie Grubbs

C linical decision-making is often fraught with uncertainties. Pat Croskerry

(2013) estimates that the diagnostic failure rate is as high as 15%. The
“Augenblick diagnosis” is one made within “the blink of an eye” based on intu-
ition, and it is a clinically dangerous state (p. 2445). While it works the majority
of the time for experienced clinicians, it fails more often than we recognize.
Croskerry (2009) describes two major types of clinical diagnostic decision-
making: intuitive and analytical. Intuitive decision-making is consistent with the
Augenblick diagnosis, in that the clinician relies on experience and intuition and
the diagnosis occurs rapidly and with little effort. However, as noted, this type
of decision-making is less reliable and paired with fairly common errors. In con-
trast, analytical decision-making is based on careful consideration, takes more
time and effort, and has greater reliability with rare errors. Because practice set-
tings present a number of distractors and competing demands, it is critical that
diagnosticians step back, assess their processes and the data they are gathering,
and attend to the possibilities.
Diagnostic reasoning involves a complex process that is quickly clouded by
first impressions. The need to ensure necessary “data” requires a measured ap-
proach, even when faced with common complaints such as chest pain. This re-
quires a consistent and measured approach to symptom analysis, physical
assessment, and data analysis. Expert diagnosticians are able to maintain a degree
of suspicion throughout the assessment process, consider a range of potential ex-
planations, and then generate and narrow their differential diagnosis on the basis
of their previous experience, familiarity with the evidence related to various
diagnoses, and understanding of their individual patient. Through the process,
clinicians perform assessment techniques involving both the history and physical
examination in an effective and reliable manner and then select appropriate
diagnostic studies to support their assessment.

2
4363_Ch01_001-011 03/10/14 11:51 AM Page 3

Chapter 1 | Assessment and Clinical Decision-Making: An Overview 3

History
Among the assessment techniques essential to valid diagnosis is performing a
fact-finding history. To obtain adequate history, providers must be well organized,
attentive to the patient’s verbal and nonverbal language, and able to accurately
interpret the patient’s responses to questions. Rather than reading into the
patient’s statements, they clarify any areas of uncertainty. The expert history, like
the expert physical examination, is informed by the knowledge of a wide range
of conditions, their physiological bases, and their associated signs and symptoms.
The ability to draw out descriptions of the patient’s symptoms and experiences
is important because only the patient can tell his or her story. To assist the patient
in describing a complaint, a skillful interviewer knows how to ask salient and
focused questions to draw out necessary information without straying (i.e., avoid-
ing a shotgun approach, with lack of focus). The provider should know, based
on the chief complaint and any preceding information, what other questions are
essential to the history. It is important to determine why the symptom brought
the patient to the office—that is, the significance of this symptom to the patient,
which may uncover the patient’s anxiety and the basis for his or her concern. It
may also help to determine severity in a stoic patient who may underestimate or
underreport symptoms.
Throughout the history, it is important to recognize that patients may forget
details, so probing questions may be necessary. Patients sometimes have trouble
finding the precise words to describe their complaint. However, good descriptors
are necessary to isolate the cause, source, and location of symptoms. Often,
patients must be encouraged to use common language and terminology. For
instance, encourage the patient to describe the problem just as he or she would
describe it to a relative or neighbor.
The history should include specific components (summarized in Table 1.1)
to ensure that the problem is comprehensively evaluated. The questions to include
in each component of the history are described in detail in subsequent chapters.

Table 1.1
Components of History
Component Purpose
Chief complaint To determine the reason patient seeks care. Important to consider
using the patient’s terminology. Provides “title” for the encounter.
History of present illness To provide a thorough description of the chief complaint and current
problem. Suggested format: P-Q-R-S-T.
• P: precipitating and palliative factors To identify factors that make symptom worse and/or better; any pre-
vious self-treatment or prescribed treatment; and response.
• Q: quality and quantity descriptors To identify patient’s rating of symptom (e.g., pain on a 1–10 scale)
and descriptors (e.g., numbness, burning, stabbing).
• R: region and radiation To identify the exact location of the symptom and any area of radiation.

Continued
4363_Ch01_001-011 03/10/14 11:51 AM Page 4

4 Advanced Assessment | The Art of Assessment and Clinical Decision-Making

Table 1.1
Components of History—cont’d
Component Purpose
• S: severity and associated symptoms To identify the symptom’s severity (e.g., how bad at its worst) and any
associated symptoms (e.g., presence or absence of nausea and vomit-
ing associated with chest pain).
• T: timing and temporal descriptions To identify when complaint was first noticed; how it has changed/
progressed since onset (e.g., remained the same or worsened/
improved); whether onset was acute or chronic; whether it has
been constant, intermittent, or recurrent.
Past medical history To identify past diagnoses, surgeries, hospitalizations, injuries,
allergies, immunizations, current medications.
Habits To describe any use of tobacco, alcohol, drugs, and to identify patterns
of sleep, exercise, etc.
Sociocultural To identify occupational and recreational activities and experiences,
living environment, financial status/support as related to health-care
needs, travel, lifestyle, etc.
Family history To identify potential sources of hereditary diseases; a genogram is
helpful. The minimum includes first-degree relatives (i.e., parents,
siblings, children), although second and third orders are helpful.
Review of systems To review a list of possible symptoms that the patient may have noted
in each of the body systems.

Physical Examination
The expert diagnostician must also be able to accurately perform a physical as-
sessment. Extensive, repetitive practice; exposure to a range of normal variants
and abnormal findings; and keen observation skills are required to develop phys-
ical examination proficiency. Each component of the physical examination must
be performed correctly to ensure that findings are as valid and reliable as possible.
While performing the physical examination, the examiner must be able to
• differentiate between normal and abnormal findings.
• recall knowledge of a range of conditions, including their associated signs
and symptoms.
• recognize how certain conditions affect the response to other conditions in
ways that are not entirely predictable.
• distinguish the relevance of varied abnormal findings.
The aspects of physical examination are summarized in the following chapters
using a systems approach. Each chapter also reviews the relevant examination for
varied complaints. Along with obtaining an accurate history and performing a
physical examination, it is crucial that the clinician consider the patient’s vital
signs, general appearance, and condition when making clinical decisions.
4363_Ch01_001-011 03/10/14 11:51 AM Page 5

Chapter 1 | Assessment and Clinical Decision-Making: An Overview 5

Diagnostic Studies
The history and physical assessment help to guide the selection of diagnostic
studies. Diagnostic studies should be considered if a patient’s diagnosis remains
in doubt following the history and physical. They often help establish the severity
of the diagnosed condition or rule out conditions included in the early differential
diagnosis. Just as the history should be relevant and focused, the selection of di-
agnostic studies should be judicious and directed toward specific conditions under
consideration. The clinician should select the study (or studies) with the highest
degree of sensitivity and specificity for the target condition while also considering
cost-effectiveness, safety, and degree of invasiveness. Selection of diagnostics re-
quires a range of knowledge specific to various studies and the ability to interpret
the study’s results.
Resources are available to assist clinicians in the selection of diagnostic studies.
For example, the American College of Radiology’s Appropriateness Criteria pro-
vides guidelines on selecting imaging studies (see www.acr.org/Quality-Safety/
Appropriateness-Criteria). A number of texts review variables relative to the
selection of laboratory studies. Subsequent chapters identify specific studies that
should be considered for varied complaints, depending on the conditions
included in the differential diagnosis.

Diagnostic Statistics
In the selection and interpretation of assessment techniques and diagnostic stud-
ies, providers must understand and apply some basic statistical concepts, includ-
ing the tests’ sensitivity and specificity, the pretest probability, and the likelihood
ratio. These characteristics are based on population studies involving the various
tests, and they provide a general appreciation of how helpful a diagnostic study
will be in arriving at a definitive diagnosis. Each concept is briefly described in
Table 1.2. Detailed discussions of these and other diagnostic statistics can be
found in numerous reference texts.
Bayes’s theorem is frequently cited as the standard for basing a clinical decision
on available evidence. The Bayesian process involves using knowledge of the
pretest probability and the likelihood ratio to determine the probability that a
particular condition exists. Given knowledge of the pretest probability and a par-
ticular test’s associated likelihood ratio, providers can estimate posttest probability
of a condition based on a population of patients with the same characteristics.
Posttest probability is the product of the pretest probability and the likelihood
ratio. Nomograms are available to assist in applying the theorem to clinical rea-
soning. Of course, the process becomes increasingly more complex as multiple
signs, symptoms, and diagnostic results are incorporated.
Reliable and valid basic statistics needed for evidence-based clinical reasoning
are not always readily available. Even when available, they may not provide a
valid representation of the situation at hand. Sources for the statistics include
textbooks, primary reports of research, and published meta-analyses. Another
4363_Ch01_001-011 03/10/14 11:51 AM Page 6

6 Advanced Assessment | The Art of Assessment and Clinical Decision-Making

Table 1.2
Clinical Statistics
Statistic Description
Sensitivity The percentage of individuals with the target condition who would have an abnormal, or posi-
tive, result. Because a high sensitivity indicates that a greater percentage of persons with the
given condition will have an abnormal result, a test with a high sensitivity can be used to rule
out the condition for those who do not have an abnormal result. For example, if redness of the
conjunctiva is 100% sensitive for bacterial conjunctivitis, then conjunctivitis could be ruled out
in a patient who did not have redness on examination. However, the presence of redness
could indicate several conditions, including bacterial conjunctivitis, viral conjunctivitis, corneal
abrasion, or allergies.
Specificity The percentage of healthy individuals who would have a normal result. The greater the speci-
ficity, the greater the percentage of individuals who will have negative, or normal, results if
they do not have the target condition. If a test has a high level of specificity so that a signifi-
cant percentage of healthy individuals are expected to have a negative result, then a positive
result would be used to “rule in” the condition. For example, if a rapid strep screen test is 98%
specific for streptococcal pharyngitis and the person has a positive result, then he or she has
“strep throat.” However, if that patient has a negative result, there is a 2% chance that the
patient’s result is falsely negative, so the condition cannot be entirely ruled out.
Pretest probability Based on evidence from a population with specific findings, this probability specifies the
prevalence of the condition in that population, or the probability that the patient has the
condition on the basis of those findings.
Likelihood ratio This is the probability that a positive test result will be associated with a person who has the
target condition, and a negative result will be associated with a healthy person. A likelihood
ratio above 1.0 indicates that a positive result is associated with the disease; a likelihood ratio
less than 1.0 indicates that a negative result is associated with an absence of the disease. Like-
lihood ratios that approximate 1.0 provide weak evidence for a test’s ability to identify individ-
uals with or without a condition. Likelihood ratios above 1.0 or below 0.1 provide stronger
evidence relative to the test’s predictive value. The ratio is used to determine the degree to
which a test result will increase or decrease (from the pretest probability) the likelihood that
an individual has a condition.

source of statistics, the one that has been most widely used and available for ap-
plication to the reasoning process, is the recall or estimation based on a provider’s
experience, although these are rarely accurate. Over the past decade, the avail-
ability of evidence on which to base clinical reasoning is improving, and there is
an increasing expectation that clinical reasoning be based on scientific evidence.
Evidence-based statistics are also increasingly being used to develop resources to
facilitate clinical decision-making.

Clinical Decision-Making Resources

Clinical decision-making begins when the patient first voices the reason for seeking
care. Expert clinicians immediately compare their patients’ complaints with the
“catalog” of knowledge that they have stored about a range of clinical conditions
and then determine the direction of their initial history and symptom analysis. It
4363_Ch01_001-011 03/10/14 11:51 AM Page 7

Chapter 1 | Assessment and Clinical Decision-Making: An Overview 7

is crucial that the provider not jump to conclusions or be biased by one particular
finding; information is continually processed to inform decisions that guide further
data collection and to begin to detect patterns in the data.
Depending on the amount of experience in assessing other patients with the
presenting complaint, a diagnostician uses varied systems through which infor-
mation is processed and decisions are made. Through experience, it is possible
to see clusters or patterns in complaints and findings and compare against what
is known of the potential common and urgent explanations for the findings. Ex-
perience and knowledge also provide specifics regarding the statistics associated
with the various diagnostic options. However, experience is not always adequate
to support accurate clinical decision-making, and memory is not perfect. To assist
in clinical decision-making, a number of evidence-based resources have been de-
veloped to assist the clinician. Resources such as algorithms and clinical practice
guidelines assist in clinical reasoning when properly applied.
Algorithms are formulas or procedures for problem-solving and include both
decision trees and clinical prediction rules. Decision trees provide a graphical de-
piction of the decision-making process, showing the pathway based on findings
at various steps in the process. A decision tree begins with a chief complaint or
physical finding and then leads the diagnostician through a series of decision
nodes. Each decision node or decision point provides a question or statement re-
garding the presence or absence of some clinical finding. The response to each of
these decision points determines the next step. (An example of a decision tree is
provided in Figure 13.5, which illustrates a decision-making process for amen-
orrhea.) These decision trees are helpful in identifying a logical sequence for the
decisions involved in narrowing the differential diagnosis and providing cues to
questions that should be answered and/or tests that should be performed
through the diagnostic process. A decision tree should be accompanied by a
description of the strength of the evidence on which it has been developed as
well as a description of the settings and/or patient population to which it relates.
Clinical decision (or prediction) rules provide another support for clinical
reasoning. Clinical decision rules are evidence-based resources that provide prob-
abilistic statements regarding the likelihood that a condition exists if certain
variables are met with regard to the prognosis of patients with specific findings.
Decision rules use mathematical models and are specific to certain situations,
settings, and/or patient characteristics. They are used to express the diagnostic
statistics described earlier. The number of decision, or predictive, rules is
growing, and select examples are included in this text. For instance, the Ottawa
ankle and foot rules are described in the discussion of musculoskeletal pain in
Chapter 14. The Gail model, a well-established rule relevant to screening for
breast cancer, is discussed in Chapter 9. Many of the rules involve complex
mathematical calculations, but others are simple. In addition to discussions of
tools, this text provides several sources of electronic “calculators” based on rules.
Box 1.1 includes a limited list of sites with clinical prediction calculators. These
resources should be accompanied by information describing the methods by
which the rule was validated.
4363_Ch01_001-011 03/10/14 11:51 AM Page 8

8 Advanced Assessment | The Art of Assessment and Clinical Decision-Making

Box 1.1
Online Sources of Medical Calculators
Essential Evidence Plus
www.essentialevidenceplus.com
MedCalc 3000 Online Clinical Calculators
www.calc.med.edu/cc-idx.htm
Medical Algorithms Project
www.medal.org
National Center for Emergency Medicine Informatics
www.med.emory.edu/EMAC/curriculum/informatics.html
National Institutes of Health
www.nih.gov
Note: Sites active as of November 17, 2013. Other subscription-based sites are also available.

Clinical practice guidelines have also been developed for the assessment and
diagnosis of various conditions. They are typically developed by national advisory
panels of clinical experts who base the guidelines on the best available evidence.
An easily accessible source of evidence-based guidelines is the National Guideline
Clearinghouse, which provides summaries of individual guidelines as well as syn-
theses and comparisons on topics if multiple guidelines are available. Like deci-
sion trees and diagnostic rules, guidelines should be accompanied by a description
of their supporting evidence and the situations in which they should be applied.
These resources are not without limitations, and it is essential that they be ap-
plied in the situations for which they were intended. In applying these tools to
clinical situations, it is essential that the diagnostician determine the population
for which the tool was developed, ensure the tool is applicable to the case at hand,
and have accurate data to consider in the tool’s application. For instance, a clinical
prediction rule based on a population of young adult college students is not valid
if applied to an elderly patient. The provider must also recognize that these re-
sources are intended to assist in the interpretation of a range of clinical evidence
relevant to a particular problem, but they are not intended to take the place of
clinical judgment, which rests with the provider.

The Diagnostic Process

As data is collected through the history and physical examination, providers tailor
their approach to subsequent data collection. They begin to detect patterns that
guide the development of a differential diagnosis that is based on an understand-
ing of probability and prognosis. This means that conditions considered are those
4363_Ch01_001-011 03/10/14 11:51 AM Page 9

Chapter 1 | Assessment and Clinical Decision-Making: An Overview 9

that most commonly cause the perceived cluster of data (probability) as well as
conditions that may be less common but would require urgent detection and
action (prognosis).
When teaching health assessment, several adages are frequently used to en-
courage novice diagnosticians to always consider clinical explanations that are
most likely to explain a patient’s situation. For instance, students often are told,
“Common diseases occur commonly.” Most clinicians learn to use the term zebra
to refer to less likely (and more rare) explanations for a presentation, adhering to
the adage “When you hear hooves in Central Park, don’t look for zebras.” Both
adages direct novices to consider the most likely explanation for a set of findings.
This text describes common conditions that should be considered in the differ-
ential diagnosis of common complaints as well as some of the less common pos-
sibilities. With the emergence of conditions, zebras may well be responsible for
findings, and providers must always maintain some level of suspicion for these
less common explanations.
Even though it is appropriate that conditions with high probabilities be con-
sidered in the differential diagnosis, it is also vital in the diagnostic process to
consider conditions that put the patient at highest risk. To do otherwise places
the patient in jeopardy of life-threatening or disabling complications. These life-
threatening situations are often referred to as red flags, which are clues signaling
the high likelihood of an urgent situation requiring immediate identification and
management. This text includes red flags for the various systems to promote their
recognition in clinical practice.
Finally, as Chapter 2 on genetic assessment describes, some patients are at
higher risk than others for certain conditions. The ability to identify genetic pat-
terns is becoming increasingly important as we learn more about the role genetics
play in many diseases.
As the potential list of conditions in the differential diagnosis develops, the
provider determines what, if any, diagnostic studies are warranted to confirm or
rule out specific diagnoses. Knowledge of the tests’ specificity and sensitivity is
helpful in the selection process. The diagnostician then combines the knowledge
gained through the history and physical assessment with the findings from any
diagnostic studies to assess the probability for the conditions remaining in the
differential diagnosis.
Times arise when a definitive diagnosis is not identified, yet urgent explanations
have been ruled out. In these situations, options include moving forward with ad-
ditional diagnostic measures, including further history, physical examination, di-
agnostic studies, and/or referral or consultation. Another option involves waiting
briefly before further diagnostic studies are performed in order to see whether or
not the condition declares itself. In this case, serial assessments should be scheduled
over a period of days or weeks in order to arrive at a diagnosis. An important factor
involved in the decision to wait is the patient’s ability and willingness to return for
follow-up at the specified intervals. In situations such as emergency department or
urgent care center visits, the clinician has no long-term relationship with the patient,
and the likelihood of the patient returning for follow-up is greatly decreased.