CLINICAL REASONINGdr. Rahma Triliana, S.Ked. M.Kes

CLINICAL REASONING IS THE MOST ESSENTIAL SKILL NEEDED TO PRACTICE MEDICINE

Clinical Reasoning Leads to Decision-Making How do clinicians use their knowledge to arrive at diagnostic and management decisions?

Clinical Reasoning and Decision-Making

(Bordage, G. Academic Medicine, 1994, 1999)

Reduced (empty mind)Dispersed(cluttered mind)

Elaborated (deductive thinking)Compiled (recall/recognition)

What do we know about clinical reasoning and decision-making?Effective reasoning and decision-making is knowledge dependentCompetent clinicians use deductive reasoning (elaborated thinking) or recall/recognition (compiled thinking) Expertise is case/problem specific (central role of knowledge) Thoroughness of data gathering is unrelated to diagnostic accuracy; compiled clinicians focus on only key issues

CLINICAL REASONING, ASSESSMENT & PLANDetailed History taking & Thorough physical examsAnalyze & Identify problems that needed to be solvedForm an assessment Plan your actionRecord

BASIC SKILL NEEDEDEnough Knowledge of MedicineAnalitical/Logical Thinking Abitilty to reasonCuriousityThoroughness (in certain occation)Open Mind Accept any possibilityFor the Greater Good

CLINICAL PROCESSS = Subjective = History taking (patients or family) O = Objective = Physical exam & laboratory test Make up the core elements based on factual & descriptive result of patientsA = Assesment = Analysis & interpretation = clustered relevant information, analyze possible meanings, logically explain with medical science (pathogenesis)P = Plan intervention (patient response, good interpersonal skill, sensitivity to patients goal, economic, responsibility, family structure & Dynamics)Record fasilitate critical thinking, communication & coordination with other health care professionals, document patients problems & progress & medicolegal purposes.

HOW TO REASON CLINICALLYTo practice think at the beginning of patient encountersFocus on finding answers to;Whats wrong with this patient?What are the problems and the diagnosis?Do Steps in Clinical Reasoning (identify problems & making diagnosis)

BEGINNING OF PATIENT ENCOUNTERSTry Asking Patient in This StepWhats wrong with you? Complaint/sWhere do you feel it? Location/AnatomyWhen did it happen? (Onset & duration) Time How did It happen? Suspected MechanismWhat relieve/aggreviate it? Involving factorsThink onWhy the problem Occurs in this patient? PathogenesisWhat is the diagnosis? Treatment & Plan

PRACTICE

STEPS of CLINICAL REASONINGIdentify Abnormal FindingsLocalize findings anatomicallyInterpret findings in term of probable processMake hypotheses about the nature of patients problemTest The hypotheses & establish a Working DiagnosisDevelop a plan agreeable to the patients

IDENTIFY ABNORMAL FINDINGSMake symthoms ListMake signs listPlan laboratory test needed (begin with basic lab e.g. CBC, urinalysis, Liver Function Test, & Renal Function Test)Make list of abnormal laboratory findingsMake additional laboratory test if needed

LOCALIZE FINDINGS ANATOMICALLYPlace the simpthoms or sign in local or regional area anatomically.e.g. Diarrea may be GIT problems, Cough may be due to thorax problemCareful with symthoms and sign that can be interpret for many human body systemsSet a local body region or system regionIf the sign cant be localized (e.g fever, fatique, malaise), try to make clustered data that help to select most probable cause of disease

INTERPRET FINDINGS IN TERM OF PROBABLE PROCESSIdentify Pathological process involving a disease of a body structureClassify to : Congenital, Infection/inflammation, Immunologic, Neoplastic, Metabolic, Nutritional, Degenerative, Vaskular, Traumatic, and Toxic Consider pathophysiologic & Psychopathologic

MAKE HYPOTHESES ABOUT THE NATURE OF PATIENTS PROBLEMDraw all your knowledge & Experience (Read again if you must)Find Patterns of abnormalities & disease then cluster them with your patientsUse evidence-based-decission making COMMON THINGS ACCURS COMMONLYSelect the most spesific & critical findings to support your hypothesisMatch your findings with againts all the conditions you know that can produce themEliminate the diagnostic possibility & select the most likely diagnosis (consider epidemiological study)Give special attention to potentially life threatening & treatable conditions & always include The WORST Case scenario in your list of diagnosis & DD

TEST YOUR HYPOTHESESAsked Further HistoryAdditional maneuvers on physical examsOther Laboratory studiesRadiologic test to confirm or to rule out tentantive diagnosisFor simple cases (out patients management, this and onward steps may not be necessary)

ESTABLISH A WORKING DIAGNOSISMention your diagnosis based on abnormal structure (e.g. hepatomegali), altered process (e.g. hypertension), or spesific cause (e.g blunt trauma)Identify other things that relate to patients life & healthPlan Health maintence (Patients education to maintain & increase health level)

DEVELOP A PLAN AGREEABLE TO THE PATIENTSIdentify & record plan for patient (diagnostic, theraupetic & education)Confirmation tests or evaluate further diagnosisConsultations to specialist or subspecialistAddition, deletions or changes in medicationsShare with your patients & seek their opinion, concern and willingness to establish good dr-patients relation)

THERAPY AS A SCIENCEDecission Making in regards to patients treatmentsBased on diagnosis process & clinical reasoningScience in giving medication evidence based medicine & Clinical TrialsCan be Psychologic, Sosial/family, Behaviour/life style changes, Pharmacologic or Surgery treatments

EG. Case INy I, 35 tahun, datang dgn keluhan demam, BAK nyeri (Disuria), rasa tak tuntas saat berkemih (Anyang-anyangen) dan nyeri pinggang. Ia juga mengeluh mual, namun tidak muntah. BAB tidak ada keluhan, & menstruasi terakhir tgl 16-08-07Hasil pemeriksaan fisik; Tensi 120/80mmhg, Nadi 80x/min, reguler, kuat. RR 18x/min & T.Ax = 38,9oC. KU lemah & anemis, Kepala, leher, thorax, & extremitas tidak ditemukan kelainan. Pada abdomen didapatkan peningkatan bising usus, pembesaran uterus setara kehamilan 14 16 minggu, dan nyeri tekan supra pubik. Flank pain dan flank mass tidak didapatkan

S : Demam, Disuria, Anyang-anyangen/urgensi, nyeri pinggang, mual (+), muntah (-). BAB taa, & HPHT 16-12-07O: Vitals = T : 120/80, N: 80x, RR : 18x,T.Ax = 38,9oC. KU= lemah, kesadaran Compos mentisKepala = anemis +/+, Icteric -/-, edema palp -/-Leher = Tyroid & trachea dBN, Pembesaran Lnn Leher (-) Thorax = Bentuk normal, Cor = Ictus cordis visible but not palpable RHM = ICS IV, SL Dex. LHM = ICS V, MCL Sin S1-S2 tunggal, Murmur (-)Pulmo = Rh -/- wh -/-Abdomen = Bising Usus + (), Hepar = tidak teraba, Lien = Tidak terabaUterus palpabel 3 jari atas symphisis pubis (14 16 minggu)Nyeri tekan suprapubikFlank Pain - / -, Flank Mass - / -Extremitas = Atas: Motoris +5 / +5 Sensoris N / N Edema -/- Bawah: Motoris +5 / +5 Sensoris N / N Edema -/-

O : Wdx: Cystitis + Amenorhea dd: Uretritis Pielonephritis GlomerulonephritisP : Dx : DL, UL, Ureum Creatinine, Uric Acid, SGOT, SGPT. Kultur urine USG Abdomen Plano test Tx : MRS Infus D5% : RL = 25 tetes/menit Amoxicillin 3 x 1 gr IV (test dulu) Novalgin 3 x 1 amp IV, Prn panas Farbion 3 x 1 amp IM Tirah baring Observasi VS / 4 jam diet TKTP KIE keluarga

Clinical ReasoningIs Not Something That You Can Achieve Overnight But Its A Results Of Simple Means Of Common-sense & Perseverance

The significance of a man is not in what he attains but in what he longs to attain. (Kahil Gibran)We are what we repeatedly do. Excellence, therefore, is not an act but a habit. (Aristotle)It does not matter how slowly you go so long as you do not stop. Confucius We are still masters of our fate. We are still captains of our souls. (Winston Churchill)