clinical reasoning fcp

8/18/2019 Clinical Reasoning FCP

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Clinical Reasoning

Zayadi Zainuddin, MD, M.Med.Ed

Medical Program Study

University Of Bengulu


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Clinical Reasoning

!t"e cognitive #rocess necessary to evaluate

and manage a medical #ro$lem%

Reasoning

&no'ledgeSill


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&ey Element Of Clinical

Diagnostic ReasoningPatient story

Data

Problem representation

(y#ot"esis

)llness scri#t

Diagnosis

&no'ledge

Conte*t

E*#erience


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Data +cuisition

- Based on no'ledge, e*#erience, and

ot"er im#ortant conte*t

- Elements

/ (istory,

/ 0indings on #"ysical e*amination,

/ Results of la$oratory testing and

imaging studies


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Pro$lem Re#resentation

- 1"e 'ay to translate a #resentation of sym#toms andsigns into a co"erent clinical case

- 1ransformation of #atient2s#ecific details into a$stract

3medical4 terms, using semantic qualifiers, in one-sentence summary

- Clinicians may "ave no conscious a'areness of t"iscognitive ste#

- 1"e #ro$lem re#resentation, unless elicited in t"eteac"ing setting, is rarely articulated


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Semantic 5ualifiers

- Paired o##osing descri#tors t"at can $e used to compare and contrast diagnostic considerations

- +ssociated 'it" strong clinical reasoning→ "el# t"e doctors sort t"roug"differential diagnoses

- Several im#lied #airs '"en considering "y#ot"eses for a diagnosis of gout / multi#le 3not single4, / discrete 3not continuous4 e#isodes, / a$ru#t 3not gradual4 onset, / severe 3not mild4 #ain, / single 6oint 3not multi#le 6oints4

Problem representation acute onset of a recurrent, #ainful,

monoarticular #rocess in an ot"er'ise "ealt"y middle2aged man


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)llness Scri#t &ey 1o Pattern

Recognition- 7enerated $y reading and $y e*#erience

- (as a #redicta$le structure / #redis#osing conditions, / #at"o#"ysiological insult,

/ clinical conseuences

- +not"er structure / e#idemiology, / tem#oral #attern,

/ syndrome statement

- Content t"ose elements '"ic" distinguis" among lie diseases


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)llness Scri#t

- 1"e defining and discriminating clinical featuresof a disease, condition, or syndrome $ecome8anc"or #oints8 in memory

- Defining features descri#tors t"at arec"aracteristic of t"e diagnoses

- Discriminating features descri#tors t"at areuseful for distinguis"ing t"e diagnoses from oneanot"er


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)llness Scri#t 7out


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)llness Scri#t

Disease AscendingCholangitis

Cholecystitis

AcuteHepatitis B

Epidemiology

Temporal Course

Syndrome

Description

Syndrome: Right Upper Quadrant Pain


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)llness Scri#t

Disease Angina PulmonaryEmbolus

SpontaneousPneumothora

x

Epidemiology

Temporal Course

Syndrome

Description

Syndrome: Acute Chest Pain

D fi i 9 Di i i ti 0 t Of +


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Defining 9 Discriminating 0eatures Of +

Set Of Diagnostic (y#ot"eses +cute

+rt"ritis


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Pattern 9 Pro$a$ilities

(y#ot"etico2Deductive Reasoning

- 1"e strategy of generating a "y#ot"esis early int"e reasoning #rocess,and t"en seeing outinformation to #rove or dis#rove t"eir t"eory$efore moving on to a different "y#ot"esis if

necessary

- 1"e model of a com$ined non2analyticalstrategy 3 pattern recognition4 'it" a more

analytical #"ase 3c"ecing key features of t"e#ro#osed diagnosis4 are effective and usedsimultaneously, in interactive fas"ion


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- Pattern recognition / essential to diagnostic e*#ertise / t"is sill is develo#ed t"roug" clinical e*#erience

- Deli$erative analytic reasoning is t"e #rimarystrategy '"en / a case is com#le* or ill defined, / t"e clinical findings are unusual, / t"e #"ysician "as "ad little clinical e*#erience 'it" t"e

#articular disease entity


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- 1"e difference $et'een novices and e*#erts / t"e s#eed 9 accuracy of t"e "y#ot"eses made, / t"e met"od and efficiency of 'eig"ing u# evidence for

and against t"e "y#ot"esis

- Some of t"is s#eed lies in t"e a$ility torecognise #atterns

- Some areas of medicine rely "eavily on #atternrecognition


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References

:. Bo'en ;>?@=:==:A2===.

=. Eva &. "at every teac"er needs to no' a$out clinicalreasoning. Med Educ =>>@F2:>?.

. Gorman 7. Researc" in clinical reasoning #ast "istory and

current trends. Med Educ =>>@H:F2H=A.H. Coderre S, Mandin (, (arasym P(, 0ic 7(. Diagnosticreasoning strategies and diagnostic success. Med Educ=>>@A?2A>.

. GendaI MR, Bordage 7. Promoting diagnostic #ro$lemre#resentation. Med Educ =>>=@?A?>2A??.


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References

?. Elstein +S, Sc"'arI +. Clinical #ro$lem solving and diagnosticdecision maing selective revie' of t"e cognitive literature. BM;=>>=@=HA=2A=.

A. &oens 0, Mann &J, Custers E, 1en Cate O1. +nalysing t"econce#t of conte*t in medical education. Med Educ=>>@:=H2:=H.

F. Stone >F@A3F4?>2?.

. +m6ad +. Clinical diagnostic reasoning and t"e curriculum amedical studentKs #ers#ective. Medical 1eac"er =>>F@>H=?2H=A.

:>. > Se#t F4. +vaila$le from UR=2>+rc"ivessc"olars>=>P


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Simulasi &asus


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Pertanyaan

:. Se$utan = #ertanyaan yang #entinganda a6uan #ada anamnesisN

=. Se$utan = macam #emerisaan fisi

yang #enting anda lauanN. Se$utan diagnosis $anding yang

#aling mungin ter6adi #ada asus iniN

H. Se$utan = 6enis #emerisaan#enun6ang yang #erlu anda lauanN


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&asus :

- Gn +, #erem#uan, =H ta"un, datang e

#olilini dengan elu"an nyeri ulu "ati

se6a = "ari yang lalu.


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&asus =

- 1n C, lai2lai, ?> ta"un, datang e tem#at

#rate anda dengan elu"an encing

$er'arna mera" se6a H "ari yang lalu.


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&asus

- Gy D, #erem#uan, H ta"un, datang e

)7D dengan elu"an nyeri #erut anan

atas se6a = 6am yang lalu.


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&asus

- 1n E, lai2lai, ? ta"un, datang e )7D

dengan elu"an nyeri dada iri se6a >

menit yang lalu.


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&asus ?

- Gy 0, #erem#uan, HF ta"un, datang e

#olilini dengan elu"an $atu se6a ?

minggu yang lalu.


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&asus A

- Gy 7, #erem#uan, ta"un, datang e

)7D dengan elu"an dada $erde$ar2de$ar

se6a > menit yang lalu.

clinical reasoning fcp

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