Clinical Reasoning. Your (and my) Goals Patient care Medical knowledge Interpersonal & communication...
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Transcript of Clinical Reasoning. Your (and my) Goals Patient care Medical knowledge Interpersonal & communication...
Clinical Reasoning
Your (and my) Goals
Patient care Medical knowledge Interpersonal & communication skills Professionalism Practice-based learning Systems-based practice
But why are you here???
Patient care Medical knowledge Interpersonal & communication skills Professionalism Practice-based learning Systems-based practice
But why are you here???
Learn to make a diagnosis
Assimilate complex clinical information into patient relevant plans
…to become a physician… (it’s more than a title)
Objectives
Understand physicians’ diagnostic reasoning strategy
Identify gaps and barriers to clinical reasoning
Identify strategies for improving clinical decisions
Basic Patient Rights/Bill of Rights
Information for patients Choice of providers and plans Access to emergency services Taking part in treatment decisions Respect and non-discrimination Confidentiality of health information Complaints and appeals Consumer responsibilities
Basic Patient Rights:
Every patient deserves:A diagnosisA treatment plan/optionsAn expected course
Clinical Vignette
Vignette
72 year-old male with dyspnea, nausea PMH: COPD, CAD, CHF (EF 40%), HTN, HLP, CKD, OA Meds:
Lisinopril/HCTZ (Zestoretic) Aspirin (Ecotrin) Atorvastatin (Lipitor) Tiotropium (Spiriva) Fluticasone/salmeterol (Advair)
Allergies: None Social: 1 PPD tobacco use (110 pack years)
Vignette
Exam: HR: 107 RR: 32 Temp: 100.1 BP: 102/62 SpO2: 96% on 2L Pain: 2/10
Why is Clinical Reasoning Difficult?
No absolutes:A + B = CA + B = DC ≠ D
Why is Clinical Reasoning Difficult?
No absolutes:A + B (+/- X) = CA + B (+/- Y) = DC ≠ D
The answer may be evolving or an unknown disease
How I Think…Data Gathering
Problem Identification
Differential
Diagnosis
Treatment
Data Gathering
Problem Identification
-History
-Physical
-Labs
-Studies-Chief complaint
-Discovered problems
-Formulate one sentence summary
Pitfalls:
1. Failure to recognize a problem2. Inability to summarize 2. Patient-directed bias3. Knowledge deficit
Data Gathering
Problem Identification
Differential
Use “Illness Scripts”:
1. Combine symptoms andproblems to get diagnoses 2. Arrange by order of likelihood
Illness Scripts
Knowledge
- Knowledge of diseases
- Understanding of pathophysiology of disease process
- Symptom clusters:
-Ex. Fever + cough + dyspnea = ???
Experience
- Exposure to disease in past
- Reinforcement of clinical patterns
- Familiarity with complex symptom clusters
- Ex. Repeated exposure to heart failure exacerbations
Context- Clinical “situational awareness”
- Co-morbid conditions
Differential Diagnosis
Knowledge
ExperienceContext
- Develop from illness scripts
- Hypothesis formation
- Order by likelihood of disease
- Allows for completeness when scripts are not fully developed
Differential Diagnosis
Knowledge
ExperienceContext
For each potential diagnosis:
- Consider prevalence - Consider risk factors - Consider RISK of disease
22 year-old male smoker with dyspnea:
Knowledge
- Asthma is caused by reversible airway obstruction
- This is treated with beta agonists and corticosteroids
Experience
- Asthma patients usually have significant dyspnea and wheezing on exam
- Patient’s with asthma exacerbation usually respond quickly to therapyContext- The patient fits the profile of a poorly controlled asthmatic
- Pollen counts are very high at this time of year
Differential Diagnosis
Knowledge
ExperienceContext
- “Hypothesis formation” – Patient has asthma exacerbation
-Patient could also have:-Pneumonia-Bronchitis-Sinusitis-Vocal cord dysfunction-Pulmonary embolism-Myocardial infarction
Data Gathering
Problem Identification
Differential
DiagnosisEstablishing the Diagnosis:
1. Perform diagnostic tests and procedures to confirm hypothesis2. Evaluate “Illness Scripts”3. Compare and contrast
Data Gathering
Problem Identification
Differential
Diagnosis
Treatment
Problem Areas
Data Gathering
- Failure to obtain pertinent history
- Lack of medical records
- Failure to perform adequate exam
- Preoccupation with extraneous details
Problem Identification
- Failure to synthesize pertinent items
- Focus on unimportant details
- Missed problems
Problem Areas
- Preoccupation with zebras
- Lack of hypothesis formation
- Difficulty with prioritization
- Bias/Tunnel vision
Differential
Diagnosis
- Fear of commitment
- Misinterpretation of data
- Failure to reassess response to treatment
More Diagnositic Pitfalls
Using a problem as a diagnosisExamples: dyspnea; cough; fever
Using a differential as a diagnosisExample: Headache – could be migraine,
tension, or medication induced…
Several Common Errors
Availability bias:Tendency to judge the likelihood of an event by
the frequency of events (or recent exposure) ?COPD/CHF exacerbation?
Attribution bias:Patient fits a negative stereotype
Chronic pain patient presenting with “10/10” pain
Cognitive Errors
Confirmation bias: Selectively accepting or rejecting information
Make a diagnosis fit regardless of data Often subconscious decisions
Other errors: Personal emotions
Both liking and disliking a patient can affect judgment “Burnout” can affect reasoning “VIP” medicine is bad for all
Back To The Clinical Vignette
Vignette
Exam: HR: 92 RR: 32 Temp: 97.7 BP: 110/62 SpO2: 96% on 2L Pain: 2/10
Differential Diagnosis
Knowledge
ExperienceContext
- “Hypothesis formation” – Patient has ASA toxicity
-Patient could also have:-Pneumonia-COPD exacerbation-CHF exacerbation-Acute MI-Pulmonary embolism-Pneumothorax-Bacteremia
Purpose of Clinical Reasoning
To make a diagnosis
To assimilate complex clinical information into patient relevant plans (quickly and correctly)
…to become a physician… (it’s more than a title)
Resources
Resources
Bowen, Judith. “Educational Strategies to Promote Clinical Diagnostic Reasoning.” NEJM 2006;355:21:2217-25.
Elstein, A. “Clinical problem solving and diagnostic decision making.” BMJ 2002;234:324-32.
Rapezzi, C. “White coats and fingerprints:diagnostic reasoning in medicine and investigative methods of fictional detectives.” BMJ 2005;331:1491-94
Questions?
Other ApproachesName: Case: Date:
PossibleDiagnoses
Biological mechanism (pathophysiology) of disorder that results in symptoms and signs
Risk factors for illness present in patient (or worth asking about)
Other symptoms or physical examination findings that would support the diagnosis
Other information needed to make diagnosis
Factors in history, physical exam, etc., supporting diagnosis
A.
D.
C.
B.
Clinical Vignette
Clinical VignetteData Gathering
Problem Identification
Differential
Diagnosis
Treatment
Acute onset of recurrent, painful, monoarticular
arthritis in an otherwise health male
-Gout-Pseudo-gout-Septic arthritis-Osteoarthritis-Systemic syndrome-Traumatic injury
54 year-old male with sudden onset knee painand swelling, worse withmovement.