Clinical Diagnostic Reasoning

Bisatyo MardjikoenUniversitas Islam Negeri Syarif Hidayatullah

Fakultas Kedokteran & Ilmu KesehatanProgram Studi Pendidikan Dokter

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.”

Key Elements Of Clinical Diagnostic Reasoning

Data Acquisition

• Based on knowledge, experience, and other important context

• Elements:– History,– Findings on physical examination,– Results of laboratory testing and

imaging studies

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

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

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

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

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

Illness Script: Gout

Illness Script

Disease Ascending Cholangitis

Cholecystitis

Acute Hepatitis B

Epidemiology

Temporal Course

Syndrome Description

Syndrome: Right Upper Quadrant Pain

Illness Script

Disease Angina Pulmonary Embolus

Spontaneous Pneumothora

x

Epidemiology

Temporal Course

Syndrome Description

Syndrome: Acute Chest Pain

Defining & Discriminating Features Of A Set Of Diagnostic Hypotheses: Acute

Arthritis

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

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

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

References1. Bowen JL. Educational strategies to promote clinical diagnostic

reasoning. Med Educ 2006;21:2217-2225.2. Eva KW. What every teacher needs to know about clinical

reasoning. Med Educ 2005;39:98-106.3. Norman G. Research in clinical reasoning: past history and

current trends. Med Educ 2005;39:418-427.4. Coderre S, Mandin H, Harasym PH, Fick GH. Diagnostic

reasoning strategies and diagnostic success. Med Educ 2003;37:695-703.

5. Nendaz MR, Bordage G. Promoting diagnostic problem representation. Med Educ 2002;36:760-766.

References6. Elstein AS, Schwarz A. Clinical problem solving and diagnostic

decision making: selective review of the cognitive literature. BMJ 2002;324:729-732.

7. Koens F, Mann KV, Custers E, Ten Cate OT. Analysing the concept of context in medical education. Med Educ 2005;39:1243-1249.

8. Stone L. Reasoning for registrars. AFP 2008;37(8):650-653.9. Amjad A. Clinical diagnostic reasoning and the curriculum: a

medical student’s perspective. Medical Teacher 2008;30:426-427.10. 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

Simulasi Kasus

Pertanyaan

1. Sebutkan 2 pertanyaan yang penting anda ajukan pada anamnesis?

2. Sebutkan 2 macam pemeriksaan fisik yang penting anda lakukan?

3. Sebutkan 3 diagnosis banding yang paling mungkin terjadi pada kasus ini?

4. Sebutkan 2 jenis pemeriksaan penunjang yang perlu anda lakukan?

Kasus 1

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

Kasus 2

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

Kasus 3

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

Kasus 5

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

Kasus 6

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

Kasus 7

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