USMLE Step 1 Review/Clinical decision-making

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Clinical decision-making is a broad subject area covering biostatistics and epidemiology. Also covered are an approach to the patient interview, the physical examination, and the establishment of a differential diagnosis.

Patient interview

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The patient interview, or patient history, consists of:

  • chief complaint (CC)
  • history of present illness (HPI)
  • medications
  • allergies
  • past medical history (PMH)
  • past surgical history (PSH)
  • social history
  • family history
  • review of systems (ROS)

Eliciting the HPI and exploring symptoms is done systematically:

  • Onset of pain (what was the patient doing when the pain started?)
  • Palliative or Provocative factors for the pain
  • Quality of pain (burning, stabbing, aching, etc.)
  • Radiation (up to jaw, down left arm, etc.)
  • Severity of pain (usually 1 - 10 scale)
  • Timing of pain (eg: after meals, in the morning, how long it lasts, etc.)


  • Site of pain
  • Onset of pain
  • Character of pain (dull, sharp, aching, stabbing, tearing etc.)
  • Radiation of pain (eg. central abdominal pain radiating to Right Iliac Fossa)
  • Associated factors (eg. nausea/vomiting)
  • Timing of pain/duration
  • Exacerbating/alleviating factors
  • Severity of pain (usually 1 - 10 scale)


  • Aggravatiing and Alleviating factors
  • Severity
  • Character, quality
  • Location
  • Associated symptoms
  • Setting
  • Timing

(ASCLAST means let the patient talk first, then ask him/her specific questions.)

to make a differential diagnosis for a problem use the word VINDICATE V vascular I inflamation / Infection N Neoplasm D Degenerative I Intoxication C collagen disease / congenital disease A autoimmune disease T Trauma E endocrine

Differential diagnosis

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The patient interview rarely indicates a single diagnosis; rather, usually there is a list of potential diagnoses, called a differential diagnosis. Systematically thinking through a differential diagnosis ensures that all possibilities are considered. The mnemonic VITAMIN C is commonly used to accomplish this:

  • Vascular
  • Infectious
  • Traumatic
  • Autoimmune
  • Metabolic
  • Idiopathic/iatrogenic
  • Neoplastic
  • Congenital

Admission orders

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When admitting a patient to the hospital, several orders must be written. The DAVE WILMINGTON mnemonic helps to accomplish this systematically:

  • Diet
  • Activity
  • Vital signs (how often)
  • Excrement (test urine / stool)
  • Weight (how often to monitor)
  • Input/output (eg, "strict ins/outs")
  • Labs (what, how often)
  • Meds (which, route, interval)
  • I V fluids (what and at what rate)
  • Nursing care (e.g. position, wound care, up in chair, ostomy care etc)
  • General care (e.g. Physical Therapy, Respiratory Therapy etc)
  • Tests (X-ray, EKG, EEG etc)
  • Observe for reaction, seizure, neuro exams
  • Notify parameters (e.g. Temp > 100 / respiration changes)

The ADC VAAN DIML mnemonic is also used commonly:

  • Admit (23 hours, full admit, service of attending,...)
  • Diagnosis
  • Condition ("Stable", "Guarded", etc.)
  • Vitals (post-op, routine, q 1 hour, etc.)
  • Allergies
  • Activities (Strict bed rest, fall precautions, ad lib, bathroom privileges, etc.)
  • Nursing (Strict I&O's, Daily weights, Call P.R.N. whatever, etc.)
  • Diet (NPO, Regular, Clears - advance diet as tolerated, 2000 cal ADA, renal, etc.)
  • IV fluids (D5 1/2 NS c 20 KCL at 110 ml/hr, LR @ 100 ml/hr, etc.)
  • Meds (scheduled and PRN's)
  • Labs and x-ray (CBC in AM, PCXR in PACU, etc.)