Clinical Diagnostic Reasoning
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Transcript of Clinical Diagnostic Reasoning
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Clinical Diagnostic Reasoning
Bisatyo MardjikoenUniversitas Islam Negeri Syarif Hidayatullah
Fakultas Kedokteran & Ilmu KesehatanProgram Studi Pendidikan Dokter
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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.”
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Key Elements Of Clinical Diagnostic Reasoning
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Data Acquisition
• Based on knowledge, experience, and other important context
• Elements:– History,– Findings on physical examination,– Results of laboratory testing and
imaging studies
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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
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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
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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
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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
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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
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Illness Script: Gout
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Illness Script
Disease Ascending Cholangitis
Cholecystitis
Acute Hepatitis B
Epidemiology
Temporal Course
Syndrome Description
Syndrome: Right Upper Quadrant Pain
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Illness Script
Disease Angina Pulmonary Embolus
Spontaneous Pneumothora
x
Epidemiology
Temporal Course
Syndrome Description
Syndrome: Acute Chest Pain
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Defining & Discriminating Features Of A Set Of Diagnostic Hypotheses: Acute
Arthritis
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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
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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
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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
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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.
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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
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Simulasi Kasus
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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?
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Kasus 1
• Nn A, perempuan, 24 tahun, datang ke poliklinik dengan keluhan nyeri ulu hati sejak 2 hari yang lalu.
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Kasus 2
• Tn C, laki-laki, 60 tahun, datang ke tempat praktek anda dengan keluhan kencing berwarna merah sejak 4 hari yang lalu.
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Kasus 3
• Ny D, perempuan, 45 tahun, datang ke IGD dengan keluhan nyeri perut kanan atas sejak 2 jam yang lalu.
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Kasus 5
• Tn E, laki-laki, 56 tahun, datang ke IGD dengan keluhan nyeri dada kiri sejak 30 menit yang lalu.
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Kasus 6
• Ny F, perempuan, 48 tahun, datang ke poliklinik dengan keluhan batuk sejak 6 minggu yang lalu.
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Kasus 7
• Ny G, perempuan, 55 tahun, datang ke IGD dengan keluhan dada berdebar-debar sejak 30 menit yang lalu.