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Clinical Diagnostic Reasoning

Clinical Diagnostic Reasoning. Bisatyo Mardjikoen Universitas Islam Negeri Syarif Hidayatullah Fakultas Kedokteran & Ilmu Kesehatan Program Studi Pendidikan Dokter. Case Presentation. Patient’s story (male, 54 yrs):

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Clinical Diagnostic Reasoning

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  1. Clinical Diagnostic Reasoning Bisatyo Mardjikoen Universitas Islam Negeri Syarif Hidayatullah Fakultas Kedokteran & Ilmu Kesehatan Program Studi Pendidikan Dokter

  2. Case Presentation • Patient’s story (male, 54 yrs): “My left knee hurt me so much last night. I woke up from sleep. It was fine when I went to bed. Now it’s swollen. It’s the worst pain I’ve ever had. I’ve had problems like this before in the same knee, once 9 months ago and once 2 years ago. It doesn’t bother me between times.”

  3. Key Elements Of Clinical Diagnostic Reasoning

  4. Data Acquisition • Based on knowledge, experience, and other important context • Elements: • History, • Findings on physical examination, • Results of laboratory testing and imaging studies

  5. Problem Representation • The way to translate a presentation of symptoms and signs into a coherent clinical case • Transformation of patient-specific details into abstract (medical) terms, using semantic qualifiers, in one-sentence summary • Clinicians may have no conscious awareness of this cognitive step • The problem representation, unless elicited in the teaching setting, is rarely articulated

  6. Semantic Qualifiers • Paired opposing descriptors that can be used to compare and contrast diagnostic considerations • Associated with strong clinical reasoning  help the doctors sort through differential diagnoses • Several implied pairs when considering hypotheses for a diagnosis of gout: • multiple (not single), • discrete (not continuous) episodes, • abrupt (not gradual) onset, • severe (not mild) pain, • single joint (not multiple joints) Problem representation: acute onset of a recurrent, painful, monoarticular process in an otherwise healthy middle-aged man

  7. Illness Script • The way the clinical experience and knowledge stored in memory • Storage Strategy of Experts • Problem representation trigger clinical memory, permitting the related knowledge (illness script) to become accessible for reasoning

  8. Illness Script: Key To Pattern Recognition • Generated by reading and by experience • Has a predictable structure: • predisposing conditions, • pathophysiological insult, • clinical consequences • Another structure: • epidemiology, • temporal pattern, • syndrome statement • Content: those elements which distinguish among like diseases

  9. Illness Script • The defining and discriminating clinical features of a disease, condition, or syndrome become "anchor points" in memory • Defining features: descriptors that are characteristic of the diagnoses • Discriminating features: descriptors that are useful for distinguishing the diagnoses from one another

  10. Illness Script: Gout

  11. Illness Script Syndrome: Right Upper Quadrant Pain

  12. Illness Script Syndrome: Acute Chest Pain

  13. Defining & Discriminating Features Of A Set Of Diagnostic Hypotheses: Acute Arthritis

  14. Pattern & Probabilities: Hypothetico-Deductive Reasoning • The strategy of generating a hypothesis early in the reasoning process,and then seeking out information to prove or disprove their theory before moving on to a different hypothesis if necessary • The model of a combined non-analytical strategy (pattern recognition) with a more analytical phase (checking key features of the proposed diagnosis) are effective and used simultaneously, in interactive fashion

  15. Pattern & Probabilities: Hypothetico-Deductive Reasoning • Pattern recognition: • essential to diagnostic expertise  • this skill is developed through clinical experience • Deliberative analytic reasoning is the primary strategy when: • a case is complex or ill defined, •  the clinical findings are unusual, • the physician has had little clinical experience with the particular disease entity

  16. Pattern & Probabilities: Hypothetico-Deductive Reasoning • The difference between novices and experts: • the speed & accuracy of the hypotheses made, • the method and efficiency of weighing up evidence for and against the hypothesis • Some of this speed lies in the ability to recognise patterns • Some areas of medicine rely heavily on pattern recognition

  17. References • Bowen JL. Educational strategies to promote clinical diagnostic reasoning. Med Educ 2006;21:2217-2225. • Eva KW. What every teacher needs to know about clinical reasoning. Med Educ 2005;39:98-106. • Norman G. Research in clinical reasoning: past history and current trends. Med Educ 2005;39:418-427. • Coderre S, Mandin H, Harasym PH, Fick GH. Diagnostic reasoning strategies and diagnostic success. Med Educ 2003;37:695-703. • Nendaz MR, Bordage G. Promoting diagnostic problem representation. Med Educ 2002;36:760-766.

  18. References • Elstein AS, Schwarz A. Clinical problem solving and diagnostic decision making: selective review of the cognitive literature. BMJ 2002;324:729-732. • Koens F, Mann KV, Custers E, Ten Cate OT. Analysing the concept of context in medical education. Med Educ 2005;39:1243-1249. • Stone L. Reasoning for registrars. AFP 2008;37(8):650-653. • Amjad A. Clinical diagnostic reasoning and the curriculum: a medical student’s perspective. Medical Teacher 2008;30:426-427. • Lucey CR. From problem list to illness script (cited 2009 Sept 8). Available from: URL: HYPERLINK http://casemed.case.edu/curricularaffairs/scholars/2002-03Archives/scholars0203/PLtoILLgroups.pdf

  19. Simulasi Kasus

  20. Pertanyaan • Sebutkan 2 pertanyaan yang penting anda ajukan pada anamnesis? • Sebutkan 2 macam pemeriksaan fisik yang penting anda lakukan? • Sebutkan 3 diagnosis banding yang paling mungkin terjadi pada kasus ini? • Sebutkan 2 jenis pemeriksaan penunjang yang perlu anda lakukan?

  21. Kasus 1 • Nn A, perempuan, 24 tahun, datang ke poliklinik dengan keluhan nyeri ulu hati sejak 2 hari yang lalu.

  22. Kasus 2 • Tn C, laki-laki, 60 tahun, datang ke tempat praktek anda dengan keluhan kencing berwarna merah sejak 4 hari yang lalu.

  23. Kasus 3 • Ny D, perempuan, 45 tahun, datang ke IGD dengan keluhan nyeri perut kanan atas sejak 2 jam yang lalu.

  24. Kasus 5 • Tn E, laki-laki, 56 tahun, datang ke IGD dengan keluhan nyeri dada kiri sejak 30 menit yang lalu.

  25. Kasus 6 • Ny F, perempuan, 48 tahun, datang ke poliklinik dengan keluhan batuk sejak 6 minggu yang lalu.

  26. Kasus 7 • Ny G, perempuan, 55 tahun, datang ke IGD dengan keluhan dada berdebar-debar sejak 30 menit yang lalu.

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