{"id":499,"date":"2020-02-05T20:32:56","date_gmt":"2020-02-05T17:32:56","guid":{"rendered":"https:\/\/www.aciltipakademisi.org\/?p=499"},"modified":"2021-11-16T04:10:01","modified_gmt":"2021-11-16T01:10:01","slug":"test-oncesi-ve-sonrasi-olasiliklar","status":"publish","type":"post","link":"https:\/\/tatd.org.tr\/atak\/2020\/02\/05\/test-oncesi-ve-sonrasi-olasiliklar\/","title":{"rendered":"Test \u00f6ncesi ve sonras\u0131 olas\u0131l\u0131klar"},"content":{"rendered":"\n<h3 class=\"wp-block-heading\">Tan\u0131ya yakla\u015f\u0131m \u00e7e\u015fitleri<\/h3>\n\n\n\n<p>Genellikle hastalar\u0131m\u0131za tan\u0131 koymaya \u00e7al\u0131\u015f\u0131rken birbirini tamamlayan iki farkl\u0131 yakla\u015f\u0131m\u0131 bir arada uygular\u0131z: [highlight color=&#8221;yellow&#8221;]\u0130lki[\/highlight]&nbsp;bir \u015fablon ya da kal\u0131b\u0131n tespit edildi\u011fi [highlight color=&#8221;blue&#8221;]\u201cpatern tan\u0131ma\u201d[\/highlight]yakla\u015f\u0131m\u0131d\u0131r.[1-4] Erizipel ya da zona d\u00f6k\u00fcnt\u00fcs\u00fcn\u00fc g\u00f6r\u00fcp tan\u0131ma, frakt\u00fcr, hareketsizlik ve nefes darl\u0131\u011f\u0131 ile pulmoner emboli birlikteli\u011fi, bat\u0131nda \u015fi\u015flik, medusa ba\u015f\u0131, spider anjiyom mevcudiyetinde karaci\u011fer sirozu tan\u0131s\u0131 gibi hekimlerin al\u0131\u015f\u0131k olup s\u0131k g\u00f6rd\u00fckleri \u015fablonlara uyan fizik muayene bulgular\u0131 ile hikaye \u00f6zelliklerinin birle\u015ftirilmesi yoluyla konulan tan\u0131lar\u0131 belirler. [highlight color=&#8221;yellow&#8221;]\u0130kinci tan\u0131sal yakla\u015f\u0131m[\/highlight]&nbsp;ise basit bir \u015fablonun konuyu a\u00e7\u0131klamakta yetersiz kald\u0131\u011f\u0131 ve hekimlerin daha analitik bir yolda ay\u0131r\u0131c\u0131 tan\u0131lar\u0131 irdeledikleri [highlight color=&#8221;blue&#8221;]\u201colas\u0131l\u0131k temelli tan\u0131sal muhakeme\u201d[\/highlight]&nbsp;diyebilece\u011fimiz [highlight color=&#8221;blue&#8221;]\u201cprobabilistik y\u00f6ntem\u201d[\/highlight]dir.[5-9] Bu y\u00f6ntemde hikaye, fizik muayene ve bulgulara g\u00f6re hekimler muhtemel birka\u00e7 tan\u0131 belirler, her birinin olas\u0131l\u0131\u011f\u0131n\u0131 de\u011ferlendirir, bu olas\u0131l\u0131klara g\u00f6re her bir tan\u0131y\u0131 koyduracak ya d\u0131\u015flayacak testler isteyerek baz\u0131 tan\u0131lar\u0131 d\u0131\u015flay\u0131p bir tanesi \u00fczerinde yo\u011funla\u015fmaya \u00e7al\u0131\u015f\u0131rlar. \u0130lk y\u00f6ntem t\u0131p mesle\u011finin incelikleri ve mesleki tecr\u00fcbe ile yak\u0131ndan ili\u015fkiliyken, ikinci yakla\u015f\u0131m hastal\u0131klar\u0131n anatomi ve patofizyolojisi ile klinik \u00e7al\u0131\u015fmalardan elde edilen verilerin de\u011ferlendirilmesini ve uygulanan tan\u0131 testlerinin s\u0131n\u0131r ve yetkinliklerinin bilinmesini gerektirir.<\/p>\n\n\n\n<p>Bu a\u015famada en uygun yakla\u015f\u0131m, belirli bir \u015fablona uymayan belirti ve bulgular\u0131 k\u00fcmeler halinde s\u0131ralamak ve ayr\u0131 birer [highlight color=&#8221;blue&#8221;]\u201cklinik problem\u201d[\/highlight]&nbsp;halinde sebep-sonu\u00e7 ili\u015fkilerini d\u00fc\u015f\u00fcnmektir. Bu klinik problemler ay\u0131r\u0131c\u0131 tan\u0131y\u0131 yapmak \u00fczere olas\u0131l\u0131klar\u0131n ayr\u0131 ayr\u0131 de\u011ferlendirilece\u011fi bir liste olu\u015fturmaya yard\u0131mc\u0131 olur. \u00d6rne\u011fin, bat\u0131nda \u015fi\u015flik, medusa ba\u015f\u0131 ve spider anjiyom ile ba\u015fvuran hastada klinik problem olarak [highlight color=&#8221;yellow&#8221;]\u201cdefans ve rebound vermeyen, akut bat\u0131n h\u00fcviyetinde olmayan a\u00e7\u0131kl\u0131\u011f\u0131 yukar\u0131 batan matite ile giden kar\u0131n \u015fi\u015fli\u011fi\u201d[\/highlight]&nbsp;ay\u0131r\u0131c\u0131 tan\u0131 a\u00e7\u0131s\u0131ndan fikir verici bir sorun olarak listelenmelidir.<\/p>\n\n\n\n<p>Klinik problemler listelendikten sonra bu klinik problemleri a\u00e7\u0131klayacak ay\u0131r\u0131c\u0131 tan\u0131lar belirlenir ve bu tan\u0131lar\u0131n her birine bir olas\u0131l\u0131k atfedilir. Bu k\u0131s\u0131m, gereksiz tetkik ve giri\u015fimleri azaltmak a\u00e7\u0131s\u0131ndan \u00e7ok \u00f6nemlidir. T\u00fcm ay\u0131r\u0131c\u0131 tan\u0131lar i\u00e7in gerekli t\u00fcm testlerin ayn\u0131 anda yap\u0131lmas\u0131 hem hastaya ihtiya\u00e7 olandan daha fazla s\u0131k\u0131nt\u0131 ya\u015fat\u0131r, hem maliyetlidir hem de gereksizdir. Bu sebeple ay\u0131r\u0131c\u0131 tan\u0131lar kabaca 3 ana \u015fekilde grupland\u0131r\u0131l\u0131r:<\/p>\n\n\n<p>[box type=&#8221;shadow&#8221; align=&#8221;aligncenter&#8221; class=&#8221;&#8221; width=&#8221;&#8221;]<\/p>\n<ul>\n<li>en muhtemel olandan ba\u015flayarak <strong>ihtimallerine g\u00f6re (olas\u0131l\u0131k temelli ay\u0131r\u0131c\u0131 tan\u0131lar),<\/strong><\/li>\n<li>tan\u0131 konamaz ya da tedavi edilemezse <strong>hayat\u0131 tehdit edici sonu\u00e7lar\u0131n\u0131n a\u011f\u0131rl\u0131\u011f\u0131na g\u00f6re (prognoz temelli ay\u0131r\u0131c\u0131 tan\u0131lar), <\/strong>ve<\/li>\n<li><strong>tedavisi kolay, yan etkisiz ve \u00e7abuk olmas\u0131na g\u00f6re (pragmatik liste).<\/strong><strong>[10]<\/strong><\/li>\n<\/ul>\n<p>[\/box]<\/p>\n\n\n<p>[box type=&#8221;note&#8221; align=&#8221;aligncenter&#8221; class=&#8221;&#8221; width=&#8221;&#8221;][highlight color=&#8221;yellow&#8221;]Bir \u00f6rnek \u00fczerinden gidelim: [\/highlight]78 ya\u015f\u0131nda hipertansiyon ile ba\u015fvuran ancak 6 ay i\u00e7inde 10 kilo kaybetti\u011fini belirledi\u011finiz bir hasta d\u00fc\u015f\u00fcnelim. Hastam\u0131z\u0131n hikayesinde e\u015fini 6 ay \u00f6nce kaybetti\u011fini, i\u015ftahs\u0131zl\u0131\u011f\u0131 oldu\u011funu ve 40 paket-y\u0131l sigara i\u00e7me \u00f6yk\u00fcs\u00fc oldu\u011funu belirliyoruz. Ay\u0131r\u0131c\u0131 tan\u0131lar\u0131m\u0131z bu bulgu ve belirtilere g\u00f6re \u00f6ncelikle depresyon, hemen ard\u0131ndan da neoplazi y\u00f6n\u00fcnde olacakt\u0131r. Bu konuda de\u011ferlendirmeler sonu\u00e7 vermez ve bu tan\u0131lar ekarte edilirse ard\u0131ndan yeni ay\u0131r\u0131c\u0131 tan\u0131lar ile malabzorpsiyon gibi daha nadir ve d\u00fc\u015f\u00fck ihtimalli tan\u0131lara do\u011fru y\u00f6nlenilir.[\/box]<\/p>\n\n\n\n<p>Olas\u0131 tan\u0131 listesi \u015fekillendikten sonra s\u0131ralama yap\u0131p bu tan\u0131lara bir olas\u0131l\u0131k atfetmek i\u015fimizi kolayla\u015ft\u0131racakt\u0131r. Olas\u0131 tan\u0131lar\u0131m\u0131z\u0131n olas\u0131l\u0131klar\u0131 toplam\u0131 1 olacak \u015fekilde b\u00fcy\u00fckten k\u00fc\u00e7\u00fc\u011fe do\u011fru yapt\u0131\u011f\u0131m\u0131z bu liste sayesinde testlerimizi se\u00e7ece\u011fiz. [10-12]<\/p>\n\n\n\n<p>Hekimler her bir tan\u0131n\u0131n olas\u0131l\u0131\u011f\u0131n\u0131 belirlerken birka\u00e7 farkl\u0131 y\u00f6nteme ba\u015fvurabilirler. Bu y\u00f6ntemlerden biri [highlight color=&#8221;blue&#8221;]\u201cdolayl\u0131 ya da sezgisel yakla\u015f\u0131m\u201d[\/highlight]&nbsp;diyebilece\u011fimiz, hekimin benzer hastalardaki tecr\u00fcbesi yard\u0131m\u0131yla koymu\u015f oldu\u011fu tan\u0131lar\u0131 irdeledi\u011fi, bu ge\u00e7mi\u015f bilgilerden de kaba bir olas\u0131l\u0131k \u00e7\u0131kard\u0131\u011f\u0131 yakla\u015f\u0131md\u0131r. Bu yakla\u015f\u0131m m\u00fckemmel de\u011fildir, yak\u0131n zamanda g\u00f6r\u00fclen ya da abs\u00fcrt sonu\u00e7lanan vakalar daha rahat hat\u0131rlan\u0131r ve yeni kan\u0131tlar, \u00e7al\u0131\u015fmalar ve verileri dikkate almaz. Dahas\u0131, bu yakla\u015f\u0131m sadece kendi tecr\u00fcbelerimizi i\u00e7erdi\u011finden ancak kendi bilgimiz dahilinde do\u011fru olabilir. Yeterince benzer vaka g\u00f6rmemi\u015f olmak, konu hakk\u0131ndaki bilgimizin yetersizli\u011fi gibi konulardan etkilenir. Hekimin sezgileriyle \u015fekillenen bu yakla\u015f\u0131mdaki her a\u015fama bias (yanl\u0131l\u0131k) ve rastlant\u0131sal hataya a\u00e7\u0131kt\u0131r. [10,13] Eski hocalar\u0131m\u0131z bu ger\u00e7ekleri \u00e7ok \u00f6ncesinden g\u00f6rm\u00fc\u015f olacak ki, b\u00fcy\u00fck kliniklerde hastalar\u0131n tan\u0131 ve tedavilerinin planlanmas\u0131 i\u00e7in [highlight color=&#8221;yellow&#8221;]\u201ckonsey sistemi&#8221;[\/highlight]ni yerle\u015ftirmi\u015flerdir. Cerrahpa\u015fa, \u00c7apa, Hacettepe, Ankara \u00dcniversitesi gibi k\u00f6kl\u00fc kurumlar\u0131n ah\u015fap ve tarih kokan amfilerinde gen\u00e7 hekimlerin eksiksiz hale getirmeye \u00e7al\u0131\u015ft\u0131\u011f\u0131 dosyalar ile konseye \u00e7\u0131kar\u0131lan hastalar\u0131n tan\u0131 ve tedavilerinin \u015fekillendi\u011fi toplant\u0131lar veriye ula\u015fman\u0131n hi\u00e7 de kolay olmad\u0131\u011f\u0131 internet \u00f6ncesi d\u00f6nemin bence en \u00f6nemli kurumlar\u0131n\u0131n ba\u015f\u0131nda gelmektedir.<\/p>\n\n\n<p>[box type=&#8221;note&#8221; align=&#8221;&#8221; class=&#8221;&#8221; width=&#8221;&#8221;]Her ne kadar tan\u0131dan ziyade tedavi ile ili\u015fkili olsa da konsept olarak buraya uygun bir an\u0131m\u0131\u00a0aktarmak istiyorum: 10 y\u0131l kadar \u00f6nce bir ACLS kursunda e\u011fitim verirken benden hem ya\u015f\u00e7a hem de t\u0131bbi tecr\u00fcbe y\u0131l\u0131 olarak \u00e7ok daha b\u00fcy\u00fck bir kursiyer ambulans hekimimiz [highlight color=&#8221;yellow&#8221;]\u201ckendi tecr\u00fcbelerine g\u00f6re\u201d[\/highlight]\u00a0ambulans ve alanda ent\u00fcbasyonun uygun olmad\u0131\u011f\u0131n\u0131 belirterek yapmad\u0131\u011f\u0131n\u0131 s\u00f6ylemi\u015fti. Analitik bak\u0131\u015f a\u00e7\u0131s\u0131yla, o y\u0131llarda, bir ambulans hekimi taraf\u0131ndan uygulanan res\u00fcsitasyonda alanda da ambulansta da ent\u00fcbasyon olmazsa olmazlardan biri olarak kabul ediliyor ve \u00f6\u011fretiliyordu. Dahas\u0131, kan\u0131ta dayal\u0131 t\u0131bbi yeni \u00f6\u011frenen bir gen\u00e7 hekim olarak \u201ctecr\u00fcbelerime g\u00f6re\u201d denildi\u011fi zaman kulaklar\u0131mdan alev \u00e7\u0131kmaktayd\u0131. Elbette, birbirimizi ikna edemedi\u011fimizi rahatl\u0131kla s\u00f6yleyebilirim. Ancak, y\u0131l 2016\u2019ya geldi\u011finde alanda ve ambulansta ent\u00fcbasyondan ziyade g\u00f6\u011f\u00fcs bas\u0131s\u0131n\u0131n \u00f6ne \u00e7\u0131kt\u0131\u011f\u0131n\u0131 g\u00f6r\u00fcyoruz. Dahas\u0131, havayolu a\u00e7\u0131k tutup ventile edilebildi\u011fi s\u00fcrece ambu-maske ile devam etmenin sa\u011fkal\u0131m \u00fczerinde negatif etkisinin olmad\u0131\u011f\u0131n\u0131n, hatta, yeterince tecr\u00fcbesi olmayan hekim ve sa\u011fl\u0131k personelinin alanda uygulad\u0131\u011f\u0131 ent\u00fcbasyonun mortaliteyi artt\u0131rd\u0131\u011f\u0131n\u0131n g\u00f6sterildi\u011fi verilere sahibiz. Her ne kadar t\u0131bbi olmayan bireysel kayg\u0131larla ent\u00fcbasyon i\u015finin sorumlulu\u011fundan ka\u00e7mak i\u00e7in b\u00f6yle bir s\u00f6ylemde bulundu\u011fu \u00f6nyarg\u0131m\u0131 h\u00e2l\u00e2\u00a0yenemesem de bu anekdot asl\u0131nda tecr\u00fcbe ve g\u00f6zleme de sayg\u0131 duymam gerekti\u011fini bana h\u00e2l\u00e2\u00a0hat\u0131rlat\u0131r.\u00a0Bu hekim arkada\u015f\u0131m\u0131z\u0131n, y\u0131llar sonra, erken invazif giri\u015fim sayesinde sekelsiz iyile\u015fti\u011fi\u00a0anterior MI\u2019a ba\u011fl\u0131 kardiyak arestinin alanda ilk m\u00fcdahalesi esnas\u0131nda kendi meslekta\u015flar\u0131ndan biri taraf\u0131ndan ent\u00fcbe edildi\u011fini de s\u00f6ylemeden ge\u00e7emeyece\u011fim. Bu a\u00e7\u0131dan, biastan ar\u0131nd\u0131rmam\u0131z\u0131n m\u00fcmk\u00fcn olmad\u0131\u011f\u0131 tecr\u00fcbe ve sezgilerimizle \u015fekillenen yakla\u015f\u0131mlar\u0131m\u0131z\u0131 biraz analitik verilerle desteklemek yani orta yolu bulmak en do\u011frusudur diyebiliriz.[\/box]<\/p>\n\n\n\n<h3 class=\"wp-block-heading\">Test \u00f6ncesi olas\u0131l\u0131k (pre-test probability)<\/h3>\n\n\n\n<p>\u0130nternet sonras\u0131 d\u00f6nemin nimetlerinden faydalanarak tecr\u00fcbe ve bilgiyi bir araya getirmenin en do\u011fru yol oldu\u011fu konusunda hemfikir oldu\u011fumuza g\u00f6re nas\u0131l yapaca\u011f\u0131m\u0131z\u0131 biraz irdeleyelim: [highlight color=&#8221;blue&#8221;]Sezgisel yakla\u015f\u0131m\u0131n[\/highlight]&nbsp;aksine [highlight color=&#8221;blue&#8221;]\u201ctamamlay\u0131c\u0131 yakla\u015f\u0131m\u201d[\/highlight]&nbsp;diyebilece\u011fimiz y\u00f6ntemle [highlight color=&#8221;yellow&#8221;]\u201ctest \u00f6ncesi olas\u0131l\u0131klar\u0131m\u0131z\u0131\u201d[\/highlight]&nbsp;yay\u0131nlanm\u0131\u015f verilerden yola \u00e7\u0131karak belirlemeye \u00e7al\u0131\u015f\u0131r\u0131z. Uygun bir \u00e7al\u0131\u015fmada ayn\u0131 klinik problem tan\u0131sal de\u011ferlendirme ile incelenmi\u015f ve belirlenen tan\u0131lar\u0131n frekanslar\u0131 bildirilmi\u015f ise bu verileri test \u00f6ncesi olas\u0131l\u0131k olarak kullanmak son derece yerinde olacakt\u0131r. Bu a\u00e7\u0131dan g\u00f6zlemsel kohort \u00e7al\u0131\u015fmalar\u0131n asl\u0131nda ne kadar \u00f6nemli veriler sa\u011flad\u0131\u011f\u0131n\u0131 bir kez daha g\u00f6rm\u00fc\u015f oluyoruz. Kullanabilece\u011fimiz bir ba\u015fka uygun \u00e7al\u0131\u015fma tipi de klinik karar verme kurallar\u0131 olu\u015fturan \u00e7al\u0131\u015fmalard\u0131r. Bu \u00e7al\u0131\u015fmalar\u0131 y\u00fcr\u00fct\u00fcrken, ara\u015ft\u0131rmac\u0131lar, belirli bir klinik probleme sahip hastalar\u0131 (anoreksi ve kilo kayb\u0131) tan\u0131sal de\u011ferlendirmeye tabii tuttuktan sonra hastalar\u0131 hedef durum a\u00e7\u0131s\u0131ndan (bir tan\u0131, mesela malignite, ya da sonlan\u0131m, mesela mortalite) farkl\u0131 tan\u0131sal olas\u0131l\u0131klara sahip alt gruplara (d\u00fc\u015f\u00fck, orta, y\u00fcksek risk) b\u00f6lmek i\u00e7in istatistiksel y\u00f6ntemler uygularlar.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\">Test sonras\u0131 olas\u0131l\u0131k (post-test probability)<\/h3>\n\n\n\n<p>Klinik tan\u0131 dinamik bir s\u00fcre\u00e7tir. Uygulanan testlerden yeni veriler geldik\u00e7e baz\u0131 tan\u0131lar\u0131n olas\u0131l\u0131klar\u0131 azal\u0131rken di\u011ferleri artar. [highlight color=&#8221;yellow&#8221;]Olabilirlik Oranlar\u0131 (Likelihood Ratio [LR])[\/highlight]&nbsp;yeni verilerin tan\u0131sal olas\u0131l\u0131klar\u0131 ne derece de\u011fi\u015ftirece\u011fini bize bildiren en \u00f6nemli belirte\u00e7lerdir. Test \u00f6ncesi olas\u0131l\u0131k, testin sonucuna g\u00f6re bir test sonras\u0131 olas\u0131l\u0131\u011fa d\u00f6n\u00fc\u015f\u00fcr. Bu test sonras\u0131 olas\u0131l\u0131k testin pozitif oldu\u011fu durumda artarken, negatif oldu\u011fu durumda azal\u0131r. \u0130\u015fte, test \u00f6ncesi olas\u0131l\u0131\u011f\u0131n hangi test sonucuna g\u00f6re ile hangi katsay\u0131yla test sonras\u0131 olas\u0131l\u0131\u011fa d\u00f6n\u00fc\u015ft\u00fc\u011f\u00fcn\u00fc g\u00f6steren say\u0131sal de\u011fer (katsay\u0131) bu Olabilirlik Oranlar\u0131d\u0131r.<\/p>\n\n\n\n<p>\u00c7o\u011fu zaman hekimlerin tecr\u00fcbe ile edindikleri sezgileri test sonu\u00e7lar\u0131n\u0131n de\u011ferlendirmesinde gayet yeterlidir. Ancak bir test sonucunun, ay\u0131r\u0131c\u0131 tan\u0131m\u0131zda yer alan bir tan\u0131 olas\u0131l\u0131\u011f\u0131n\u0131 artt\u0131r\u0131p azalmas\u0131n\u0131n ne derece g\u00fcvenilir bir sonu\u00e7 oldu\u011fu sistematik ara\u015ft\u0131rma ve say\u0131sal de\u011ferlendirme gerektirir. Bir hastada CRP\u2019nin ya da Beyaz K\u00fcre Say\u0131s\u0131n\u0131n belirli bir e\u015fi\u011fin alt\u0131nda (negatif) olmas\u0131 ay\u0131r\u0131c\u0131 tan\u0131lar i\u00e7inde yer alan bakteriyel pn\u00f6moni ihtimalini elbette azalt\u0131r. Bu azalman\u0131n anlaml\u0131 ve g\u00fcvenilir olup olmad\u0131\u011f\u0131 ancak test do\u011frulu\u011funu g\u00f6steren \u00e7al\u0131\u015fmalar ve bu \u00e7al\u0131\u015fmalar\u0131n sistematik derlemelerinin incelenmesiyle kesin olarak s\u00f6ylenebilir.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\">Tan\u0131sal s\u00fcre\u00e7lerde test ve tedavi e\u015fikleri<\/h3>\n\n\n\n<p>Bir tan\u0131n\u0131n test \u00f6ncesi olas\u0131l\u0131\u011f\u0131 test e\u015fi\u011finin alt\u0131ndaysa o tan\u0131 ihtimali test yap\u0131lmas\u0131n\u0131 gerektirmeyecek kadar d\u00fc\u015f\u00fckt\u00fcr. E\u011fer tedavi e\u015fi\u011finin \u00fcst\u00fcndeyse o zaman da test yapmaya gerek kalmaks\u0131z\u0131n tedaviye ba\u015flanmal\u0131d\u0131r. Bir testin karar verme a\u015famalar\u0131nda fayda sa\u011flayabilmesi i\u00e7in teste endikasyon olu\u015fturan tan\u0131 ihtimalinin test e\u015fi\u011finin \u00fcst\u00fcnde, ancak tedavi e\u015fi\u011finin alt\u0131nda kalan bir oranda olmas\u0131 gerekir. Test sonu\u00e7lar\u0131n\u0131n pozitif ya da negatif olmas\u0131na g\u00f6re, o testin olabilirlik oran\u0131 (likelihood ratio) nispetinde testin konfirme etti\u011fi tan\u0131n\u0131n olas\u0131l\u0131\u011f\u0131 da artar ya da azal\u0131r. Test sonras\u0131 olas\u0131l\u0131k, test \u00f6ncesi olas\u0131l\u0131k ile test sonucunun olabilirlik oran\u0131n\u0131n \u00e7arp\u0131m\u0131na e\u015fittir. Test sonras\u0131 olas\u0131l\u0131k da t\u0131pk\u0131 test \u00f6ncesi olas\u0131l\u0131k gibi tedavi e\u015fi\u011finin \u00fcst\u00fcnde ise tedaviye ba\u015flan\u0131r, test e\u015fi\u011finin alt\u0131ndaysa tan\u0131 ekarte edilmi\u015f olur.[14,15] Bu e\u015fiklerin izafi g\u00f6sterimi a\u015fa\u011f\u0131daki \u015fekilde&nbsp;verilmi\u015ftir.<\/p>\n\n\n\n<div class=\"wp-block-image\"><figure class=\"aligncenter\"><a href=\"http:\/\/www.acilci.net\/wp-content\/uploads\/2016\/04\/\u015eekil-6.1-Testler.jpg\" data-rel=\"penci-gallery-image-content\" ><img decoding=\"async\" src=\"http:\/\/www.acilci.net\/wp-content\/uploads\/2016\/04\/ekil-6.1-Testler-e1461533096443.jpg\" alt=\"Test ve tedavi e\u015fikleri\" class=\"wp-image-18226\" \/><\/a><\/figure><\/div>\n\n\n<p>[box type=&#8221;shadow&#8221; align=&#8221;aligncenter&#8221; class=&#8221;&#8221; width=&#8221;&#8221;]Bu a\u015fama ve e\u015fiklerin her zaman say\u0131sal olarak hesaplanmas\u0131na gerek yoktur. Mesela, patern tan\u0131ma yoluyla tan\u0131 koyan tecr\u00fcbeli bir hekim dermatom \u00fczerinde klasik zona d\u00f6k\u00fcnt\u00fclerini g\u00f6rd\u00fc\u011f\u00fc anda sezgisel olarak test \u00f6ncesi olas\u0131l\u0131\u011f\u0131n\u0131n \u00e7ok y\u00fcksek, neredeyse %100\u2019e yak\u0131n oldu\u011funa kanaat getirerek tedaviye ba\u015flar. Asl\u0131nda, test \u00f6ncesi olas\u0131l\u0131\u011f\u0131n tedavi e\u015fi\u011finden y\u00fcksek oldu\u011funa karar vermi\u015ftir. Benzer \u015fekilde, ayn\u0131 hasta yan a\u011fr\u0131s\u0131 \u015fikayeti ile ba\u015fvurmu\u015f olsa muayene yapmadan \u00f6nce renal koli\u011fin y\u00fcksek olas\u0131l\u0131kl\u0131 bir tan\u0131 oldu\u011funu d\u00fc\u015f\u00fcnecektir. Yani, yan a\u011fr\u0131s\u0131 \u015fikayeti olan bir hastada renal kolik test \u00f6ncesi olas\u0131l\u0131\u011f\u0131 y\u00fcksek olan bir tan\u0131d\u0131r. Ama her biri ayr\u0131 birer test olan d\u00f6k\u00fcnt\u00fclerin varl\u0131\u011f\u0131 ve kostovertebral a\u00e7\u0131 hassasiyetinin yoklu\u011fu bulgular\u0131 sonucunda renal kolik i\u00e7in test sonras\u0131 olas\u0131l\u0131k, test e\u015fi\u011finin alt\u0131na d\u00fc\u015fer. Dolay\u0131s\u0131yla da renal kolik tan\u0131s\u0131 koymak ya da ekarte etmek i\u00e7in herhangi bir test yapmaya gerek duymadan bu tan\u0131y\u0131 ay\u0131r\u0131c\u0131 tan\u0131 listesinden \u00e7\u0131kar\u0131r. Ke\u015fke, hastalar\u0131m\u0131zdaki t\u00fcm tan\u0131lar\u0131 bu kadar kolayl\u0131kla do\u011frulay\u0131p ekarte edebilseydik. Ama ne yaz\u0131k ki, \u00e7o\u011fu zaman sezgisel yakla\u015f\u0131m\u0131m\u0131z yetersiz kal\u0131r.[\/box]<\/p>\n\n\n<p>[highlight color=&#8221;yellow&#8221;]Peki, bu test ve tedavi e\u015fiklerini nas\u0131l se\u00e7iyoruz?[\/highlight]<\/p>\n\n\n\n<p>&nbsp;Bu e\u015fikler testin g\u00fcc\u00fc ve \u00f6zellikleri, hastal\u0131\u011f\u0131n prognozu ve tedavinin do\u011fas\u0131ndan direk olarak etkilenir. Test ne kadar ucuz, kolay ve g\u00fcvenilirse, tan\u0131n\u0131n atlanmas\u0131 ne kadar tehlikeliyse, ve tan\u0131 konulursa verilecek tedavi ne kadar ula\u015f\u0131labilir ve etkinse test e\u015fi\u011fimiz de o kadar d\u00fc\u015fer. Tersi durumlarda ise test e\u015fi\u011fimizi y\u00fcksek tutar\u0131z.\n<\/p>\n\n\n<p>[box type=&#8221;shadow&#8221; align=&#8221;aligncenter&#8221; class=&#8221;&#8221; width=&#8221;&#8221;]\u00d6rne\u011fin, k\u00fcnt bat\u0131n travmas\u0131 ile ba\u015fvuran hastalarda serbest s\u0131v\u0131 tespiti i\u00e7in tecr\u00fcbeli ellerde FAST ile DPL\u2019nin do\u011fruluk, \u00f6zg\u00fcll\u00fck ve duyarl\u0131l\u0131klar\u0131n\u0131n ayn\u0131 oldu\u011fu g\u00f6sterilmi\u015ftir. Bu sebeple de ATLS, ATACC, BTACC, NICE, KADAT gibi kurs ve k\u0131lavuzlar FAST bak\u0131s\u0131n\u0131 DPL\u2019nin \u00f6n\u00fcne koymaya ba\u015flam\u0131\u015ft\u0131r.<\/p>\n<p>Peki, elimizde USG cihaz\u0131 yoksa, FAST yapmaya karar verdi\u011fimiz her hastaya DPL yapmaya da karar verir miydik? B\u00fcy\u00fck ihtimalle, intrabdominal kanama y\u00f6n\u00fcnden test \u00f6ncesi olas\u0131l\u0131\u011f\u0131m\u0131z\u0131 bir daha sorgular, ard\u0131\u015f\u0131k vital ve fizik muayenelerle test \u00f6ncesi ihtimalimizi d\u00fc\u015f\u00fcrmeye ya da y\u00fckseltmeye \u00e7al\u0131\u015f\u0131rd\u0131k. Elimizde USG varsa FAST i\u00e7in test e\u015fi\u011fimiz d\u00fc\u015f\u00fck, DPL i\u00e7in y\u00fcksektir. Bunun sebebi de giri\u015fimin invazifli\u011finden kaynaklanmaktad\u0131r.<\/p>\n<p>Az \u00f6nceki \u00f6rnekte yer alan 35 ya\u015f\u0131ndaki kar\u0131n a\u011fr\u0131s\u0131 hastas\u0131nda neredeyse t\u00fcm Acil T\u0131p hekimleri EKG isteyecektir. \u00c7\u00fcnk\u00fc EKG ucuz, non-invazif ve g\u00fcvenilir bir testtir. Belki y\u0131lda 2 en fazla 3 kez g\u00f6rebilece\u011fi 35 ya\u015f ve alt\u0131 AKS\u2019lerden birini yakalamak i\u00e7in t\u00fcm hastalara EKG \u00e7ekilmesi bile anlaml\u0131 olabilir. EKG i\u00e7in her t\u00fcrl\u00fc a\u011fr\u0131da test e\u015fi\u011fi \u00e7ok ama \u00e7ok d\u00fc\u015f\u00fckt\u00fcr.<\/p>\n<p>Ya\u015fl\u0131, immobil, malignite hikayesi olan, nefes darl\u0131\u011f\u0131 ve yan a\u011fr\u0131s\u0131 ile ba\u015fvuran, akci\u011fer filminde infiltrasyon g\u00f6r\u00fclmeyen bir hastada pulmoner emboli tan\u0131s\u0131 i\u00e7in BT anjiyogram test e\u015fi\u011fi y\u00fcksektir, DMAH ile tedavi e\u015fi\u011fi ise kontraendikasyon olmad\u0131\u011f\u0131 s\u00fcrece d\u00fc\u015f\u00fckt\u00fcr. Kontrast nefropatisi ihtimali, hastan\u0131n BT\u2019de g\u00f6r\u00fcnt\u00fc verebilip veremeyece\u011fi, ya\u015fl\u0131 ve hipoksik bir hastan\u0131n gantri i\u00e7inde monit\u00f6rizasyonunun zorlu\u011fu gibi fakt\u00f6rler bizi hemen anjiyografi order etmekten geri tutarken, bir yandan da asl\u0131nda test \u00f6ncesi tan\u0131 olas\u0131l\u0131\u011f\u0131m\u0131z \u00e7ok y\u00fcksek oldu\u011fundan direk tedavi ba\u015flay\u0131p ba\u015flamamak aras\u0131nda kal\u0131r\u0131z. Asl\u0131nda tedavi e\u015fi\u011fine olduk\u00e7a yak\u0131n bir test \u00f6ncesi olas\u0131l\u0131k s\u00f6z konusudur. Ayn\u0131 zamanda tedavi se\u00e7enekleri k\u0131s\u0131tl\u0131, alternatifleri dar ve kesin tedavisi olmayan bir tan\u0131 s\u00f6z konusudur. PE olsa bile belki de sadece DMAH alabilecek olan bu hastada bu sebeple tedavi e\u015fi\u011fi iyice d\u00fc\u015fer ve test e\u015fi\u011fine nerdeyse yakla\u015f\u0131r.<\/p>\n<p>Tam tersine, baz\u0131 malignitelerde evreleme laparatomisi ad\u0131 alt\u0131nda cerrahi, bir tedavi de\u011fil tan\u0131 testi olarak kullan\u0131l\u0131r. Malignitelerin tedavisi o kadar zorlu, pahal\u0131, invazif ve komplikedir ki tedavi e\u015fi\u011fimiz neredeyse %100\u2019e yak\u0131nd\u0131r.[\/box]<\/p>\n\n\n\n<p>Sezgisel yakla\u015f\u0131mda hekimin \u00e7al\u0131\u015ft\u0131\u011f\u0131 ortam ve klini\u011fin de \u00e7ok b\u00fcy\u00fck \u00f6nemi vard\u0131r:<\/p>\n\n\n<p>[box type=&#8221;shadow&#8221; align=&#8221;aligncenter&#8221; class=&#8221;&#8221; width=&#8221;&#8221;]\u00d6rne\u011fin, kar\u0131n a\u011fr\u0131s\u0131 \u015fikayeti ile acil servise ba\u015fvuran 35 ya\u015f\u0131nda bir hastada Acil T\u0131p hekiminin akl\u0131nda prognostik ve probabilistik ay\u0131r\u0131c\u0131 tan\u0131 listeleri ayn\u0131 anda olu\u015fur. En olas\u0131 \u00f6n tan\u0131lar indigesyon, gastroenterit, meteorizm \u015feklinde ba\u015flay\u0131p akut apandisit ile devam etse de, Acil T\u0131p hekimi [highlight color=&#8221;yellow&#8221;]\u201cakut MI ya da aritmi de olmas\u0131n\u201d[\/highlight]\u00a0demek i\u00e7in e\u011fitilmi\u015ftir. Bir Genel Cerrahi hekimi ayn\u0131 hastada sezgisel olarak \u00f6nce perforasyon, herni, akut apandisit gibi tan\u0131lar\u0131 elemeye \u00e7al\u0131\u015f\u0131r. Dermatoloji hekimi zona olmad\u0131\u011f\u0131ndan emin olmak ister. Bu a\u00e7\u0131dan her hastada tan\u0131n\u0131n ne olmas\u0131n\u0131 istedi\u011fimizi de\u011fil ne olabilece\u011fini g\u00f6zden ge\u00e7irmemiz, bununla ilgili uygun \u00e7al\u0131\u015fmalardan olas\u0131 tan\u0131lar\u0131n frekanslar\u0131n\u0131 de\u011ferlendirmemiz \u00e7ok \u00f6nemlidir.[\/box]<\/p>\n\n\n\n<h4 class=\"wp-block-heading\">Kaynaklar<\/h4>\n\n\n\n<ol class=\"wp-block-list\"><li>Eva KW. What every teacher needs to know about clinical reasoning. <em>Med Educ<\/em> 2005;<strong>39<\/strong>:98\u2013106.<\/li><li>Vijayasekaran D, Ramesh S. Teaching and Assessing Clinical Reasoning Skills. <em>Indian Pediatr<\/em> 2016;<strong>53<\/strong>:175.<\/li><li>Schmidt HG, Norman GR, Boshuizen HP. A cognitive perspective on medical expertise: theory and implication. <em>Acad Med<\/em> 1990;<strong>65<\/strong>:611\u201321.<\/li><li>Carlos WG, Kritek PA, Clay AS, Luks AM, Thomson CC. Teaching at the Bedside: Maximal Impact in Minimal Time. <em>Ann Am Thorac Soc<\/em> 2016;:AnnalsATS.201601\u2013018AS.<\/li><li>Rebitschek FG, Bocklisch F, Scholz A, Krems JF, Jahn G. Biased Processing of Ambiguous Symptoms Favors the Initially Leading Hypothesis in Sequential Diagnostic Reasoning. <em>Exp Psychol<\/em> 2015;<strong>62<\/strong>:287\u2013305.<\/li><li>Monteiro SD, Sherbino JD, Ilgen JS, Dore KL, Wood TJ, Young ME, <em>et al.<\/em> Disrupting diagnostic reasoning: do interruptions, instructions, and experience affect the diagnostic accuracy and response time of residents and emergency physicians? <em>Acad Med<\/em> 2015;<strong>90<\/strong>:511\u20137.<\/li><li>Croskerry P. A universal model of diagnostic reasoning. <em>Acad Med<\/em> 2009;<strong>84<\/strong>:1022\u20138.<\/li><li>Ilgen JS, Humbert AJ, Kuhn G, Hansen ML, Norman GR, Eva KW, <em>et al.<\/em> Assessing diagnostic reasoning: a consensus statement summarizing theory, practice, and future needs. <em>Acad Emerg Med<\/em> 2012;<strong>19<\/strong>:1454\u201361.<\/li><li>Ilgen JS, Eva KW, Regehr G. What&#8217;s in a Label? Is Diagnosis the Start or the End of Clinical Reasoning? <em>J Gen Intern Med<\/em> Published Online First: 26 January 2016. doi:10.1007\/s11606-016-3592-7<\/li><li>Guyatt G. <em>Users&#8217; Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice, 3E<\/em>. McGraw Hill Professional&nbsp; 2014.<\/li><li>Felder S, Mayrhofer T. <em>Medical Decision Making<\/em>. Berlin, Heidelberg: Springer Science &amp; Business Media&nbsp; 2011. doi:10.1007\/978-3-642-18330-0<\/li><li>Sox HC, Higgins MC, Owens DK. <em>Medical Decision Making<\/em>. Chichester, UK: John Wiley &amp; Sons&nbsp; 2013. doi:10.1002\/9781118341544<\/li><li>Richardson W. Where do pretest probabilities come from? <em>Evidence-Based Medicine<\/em> 1999;<strong>4<\/strong>:68\u20139.<\/li><li>Pauker S. The threshold approach to clinical decision making. <em>New England Journal of Medicine<\/em> 1980;<strong>302<\/strong>:1109\u201317.<\/li><li>Gross R. <em>Making Medical Decisions<\/em>. ACP Press&nbsp; 1999.<\/li><\/ol>\n","protected":false},"excerpt":{"rendered":"<p>Tan\u0131ya yakla\u015f\u0131m \u00e7e\u015fitleri Genellikle hastalar\u0131m\u0131za tan\u0131 koymaya \u00e7al\u0131\u015f\u0131rken birbirini tamamlayan iki farkl\u0131 yakla\u015f\u0131m\u0131 bir arada uygular\u0131z: [highlight color=&#8221;yellow&#8221;]\u0130lki[\/highlight]&nbsp;bir \u015fablon ya da kal\u0131b\u0131n&hellip;<\/p>\n","protected":false},"author":1561,"featured_media":501,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"inline_featured_image":false,"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[16,21,10014],"tags":[],"class_list":["post-499","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-arastirma-planlama-yazilari","category-istatistik-yazilari","category-akademik-blog-yazisi"],"acf":[],"_links":{"self":[{"href":"https:\/\/tatd.org.tr\/atak\/wp-json\/wp\/v2\/posts\/499","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/tatd.org.tr\/atak\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/tatd.org.tr\/atak\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/atak\/wp-json\/wp\/v2\/users\/1561"}],"replies":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/atak\/wp-json\/wp\/v2\/comments?post=499"}],"version-history":[{"count":0,"href":"https:\/\/tatd.org.tr\/atak\/wp-json\/wp\/v2\/posts\/499\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/atak\/wp-json\/wp\/v2\/media\/501"}],"wp:attachment":[{"href":"https:\/\/tatd.org.tr\/atak\/wp-json\/wp\/v2\/media?parent=499"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/tatd.org.tr\/atak\/wp-json\/wp\/v2\/categories?post=499"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/tatd.org.tr\/atak\/wp-json\/wp\/v2\/tags?post=499"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}