Clinical Reasoning IrfannuddinUPEP FK Unsri

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Mad Mpul MD is in trouble. He got claim by patient because of wrong diagnosis that cause him gave wrong treatment. Now, the patient has physical defect. The patient prosecute him to pay half million dollar.

Case

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Another Real CaseMr D come to dr K with skin problem. He feels his skin itchy and redness. After short 2 minutes interview, dr K ask him to follow the complete blood and scan skin. The cost of tests around 500.000 rupiahsBased on the test, dr.K just give 5 kind of drugs for Mr D. Mr D spent around 400.000 rupiahs for the drugsOne year later, when he come home to his town (Palembang), Mr D got same problem. He come to a good general doctor.After 20 minutes interview, the generic doctor conclude that Mr D got allergic problem with some tools. The doctor just give him 1 drug price 15.000 rupiahs and some good advice.After visiting the doctor and use the drug. Mr D never got the same problem anymore.

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Another Real CaseR 8 th. Selalu merasa lemah dan mudah mengantukOrang tuanya telah membawa R ke beberapa spesialis dan beberapa rumah sakit ternama di Jakarta. Mereka menetapkan diagnosis dan terapi yang bervariasi, mulai dari gangguan genetik, sindrom metabolik, gangguan defisiensi enzim sampai ke gejala kanker.Karena kehabisan uang, R dibawa orang tuanya ke Palembang untuk ditipkan ke nenek R. Di Palembang R dirawat di RSMH.Dokter RSMH melakukan pemeriksaan sederhana terhadap R berupa pemeriksaan feses.Dari pemeriksaan feses diketahui R menderita cacingan Ascaris Lumbricoides. R kemudian di beri obat cacing dan terapi cairan.Setelah beberapa minggu, kondisi R menunjukkan perbaikan. R sekarang menjadi anak yang ceria dengan prestasi belajar yang cemerlang.

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Why does clinical reasoning ?American Medical Association: > 12.000 malpractice reports/yearCauses:Misdiagnosis (>>>)MiscommunicationMismanagementIndonesia : most of them

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Causes of MisdiagnosisErrors in taking decisionInsensitive with patients dataLess knowledgeNot thinking reasonableLow ability of clinical reasoningBecker, 2008

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Doctor must think reasoning, why ?The doctor treat patient base on dataData about: Patients problemSign & symptomThe data/problem always:ImcompleteUnclearContradictiveBefuddling

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The main characteristic of professionalism in Medicine is:Thinking reasoning in unclear condition to solve the unconfirmed problem

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Medical CompetenciesClinical Reasoning (the most important)Appraise, priorities, find alternatives, evaluation etc.Clinical skillsAnamnesis, diagnosis, managementInterpersonal skillsCommunication, attitudeBasic medical knowledgeSibert, et al. (2000)

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What is Clinical Reasoning ?Cognitive processSynthetize and integrate clinical cases with knowledge and experiencesUtiliize to diagnose and treat patients problemWashington University, 2005

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Ennis, 2000Clinical ReasoningA healthy thinking to conduct clinical practiceCentral component of medical professionalismProcess : firts contact with patient reportKeyword of Clinical ReasoningProbability analysisPriority Determination

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Clinical ReasoningSantoso, Priyadi, Rizki, Irfannuddin, 2007

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How is building the Clinical Reasoning ?Clinical reasoning is a skill that could be trainedHow ?:Practice in critical thinkingPractice in logical thikingBuilding the knowledgeHave a lot experience

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Step in practicing in clinical reasoningComponent of Clinical ReasoningStep in PBLTerm clarficationIdentify problemAnalyzed problemFormulate the hypothesis hypothesisEvaluation hypothesis and determine limited knowledgeSelf learningSynthesis and evaluationPresentation in plenary

Collect, organize & interpretate data (problem)Formulate the hypothesisAnalyzed the hypothesisEvaluation and make alternative diagnosisTreatment strategy & priorityCase presentation

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Irfannuddin, 2008

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Good Skills in Clinical Reasoning :Able to:Generating prioritized problem listIdentifying tha main patient problemAccurately describing the patient problem in a detailed chronological mannerIdentifying pertinent positives and negatives for the patients problemGathering information from other parts of the medical database that supports the most likely diagnosis and refutes alternative explanationsIdentifying and accurately reporting the part of the physical examination that are importsnt to understand the patients problemSummarizing the relevant hystory and the physical findingGenerating and appropiately detailed branching diagram that reflects an organized approach to the patients problem Generating a brief differential diagnosis of the patients problemExplaining how likely each item on differential diagnosis is or is not and why

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Thats all for today

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