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Developing ClinicalProblem-Solving Skills

HirlanSub Bag Gartroenterologi HepatologiSub Bag Gartroenterologi Hepatologi

Bagian Ilmu Penyakit DalamBagian Ilmu Penyakit DalamRS Dr Kariai !K "nipRS Dr Kariai !K "nip

SemarangSemarang

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Patient#s In$ormation

Problem synt%esis&ultiple%ypot%esis

In'uirystrategy

Basic structure o$ clinical reasoning processBasic structure o$ clinical reasoning process

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Stages o$ t%e p%ysician#s clinical reasoning proc

() Hypot%esis generation

*) In'uiry strategy+) Data analysis

,) Problem synt%esis

) Diagnostic an treatment ecision-making

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De.nition o$ term

Hypot%esis /H

ypot%esis /a proposition 0 set o$ propositions

as an e1planation $or t%e occurrence o$ some speci.e group o$ p%enomena eit%er asserte merely as a pro$essional con2ecture to guie investigation or

accepte as t%e %ig%ly probable in t%e lig%t o$ establis%e $acts

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Hypot%esis

3abel 45%atever6 t%at best e1plain t%epossible causes $or t%e patients problem)

7isease processes7pat%ological processes7clinical entities 0 synrome7p%ysiological erangements

7etiological process7a8ecte organ0tissue7psyc%ological processes7social or economical $actors

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DiagnosisDiagnosis

3abel o$ isease /

- Speci.c organ

- Process - 9t%iology

!inal iagnosis

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IntuitionIntuition

Clinician#s ecision about correct 1 or t1 5%e

insu:cient ob2ective evienceor clear-cut reasons are not available

C%aracteristic o$ t%ee1perience clinician

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&etacognition&etacognition

Involves eliberation;re

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!orming t%e initial concept!orming t%e initial concept

Patient#s in$ormation

Perception

>nalysis

Initial conceptInitial concept

Details are important look at everything that could be signifcant

Be careul, the hazard obias

Keeping the initial concept exible

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Developing t%e initialconcept

=racking patient ata /73ook at t%e patient care$ully

73istening care$ully

7=ry to be as ob2ective as you can

Pull t%e in$ormation toget%er initialconcept

%ypot%esis5ill $ollo5

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Generating multiple

%ypot%esisHypot%esis are generate early in t%e patient encounter

?$ten keep t%e initial %ypot%esis very broa $rames t%e %ypot%esis in anatomical 0 pat%op%ysiological term

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Patient#s in$ormation

Perception

>nalysis

Initial concept &ultiple %ypot%In'uiry strategy

Generating multiple %ypot%esisGenerating multiple %ypot%esis

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Designing in'uiry strategy

Components o$ in'uiry strategy

- euction - insu.ciency - scan

- searc%

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Scanning

7 non-%ypot%esis oriente

systemic intervie5 an p%ysical e1amination7 complements t%e $ocuse searc% o$ euctive in'u7 time consume 0 lu1ury

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Searc%

7 Deuctive in'uiry; esigne to resolve en7 Problem oriente activity;

'uestions an e1amination are carrie ou

ata guie by %ypot%esis

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=%e %istory

!unamental $our / present illness past %istory $amily %istory psyc%osocial %is

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Present illness

Sacre seven / location 'uality

'uantity0 severity timing 4onset; uration

setting $actors t%at %ave aggr

>ssociate mani$estati

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Present illness

7 ?nset o$ symptom7 events surrouning t%e onset7 'uality an intensity o$ t%e symptom

7 associate symptom7 =emporal symptom7 Se'uence o$ symptom7 locali@ation

7 relieving an aggravating $actors

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>pproac% to t%e present illness

7greeting t%e patient7t%e patient#s com$ort7opening 'uestions7$ollo5ing t%e patient#s leas /

$acilitation re

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Revie5 o$ systems

Scanning met%oe?nly i$ neee; as complements

o$ problem oriente intervie5

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P%ysical e1amination

&ost o$ iagnosis process 5ere base on %istory91perience p%ysician usually nee only a $e5 particular

e1amination to con.rm %is iagnostic ecision

- learn care$ully %o5 to searc% t%e abnormality - al5ays consistent 5it% p%ysical e1amination tec%ni - poor tec%ni'ue can prouce $alse .ning

- al5ays learn to kno5 5%at 5e %ave to looking $or=%e rest o$ p%ysical e1amination is scanning met%o

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Patients in$ormation

Perception

>nalysis

Synt%esis 5it%

Initial concept

&ultiple

%ypot%esis

Auestions e1amination

clinical skill

in'uiry strategy

searc% an scan

Clinical skill are tool of inquiry strategy

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Patient in$ormation

Perception

>nalysis

Problem synt%esis

Diagnosis ecision

=%erapeutic ecision

=est clinical skill

In'uiry strategy

be%aviormoi.cation

Rational be%avior

Compliance

multiple %ypot%esis

Patienteucation=%e .nal step