clinical reasoning

Question 1

what is the iterative cycle

Answer 1

1. Gathering initial patient information (health history and physical examination)
2. problem representation
3. Generating hypotheses (differential diagnosis) for patient’s problem
4. Illness Script Matching
5. Planning the diagnostic and treatment strategy

Question 2

clinical reasoning: Dual process approach of Intuitive (system 1) and hypotheticodeductive (system 2) what is the difference

Answer 2

Intuitive
- FAST + automatic
- VISUAL
- Mental shortcut
- Formulaic response patterns based on formed habits
- Hard to change or manipulate

Analytical:
- Tempered, controlled thought
- Conscious judgment
- Uses logic and PROBABILITIES to come to a conclusion
- time and resource intensive

Question 3

Step 1: Gather Clinical Information and Organize Knowledge

Answer 3

• Tempo and course of CC/HPI
• Age, exposures, and risk factors
• General appearance and KEY abnormal findings on exam
• Recognize pertinent positives AND negatives
• Recognize if the clinical data fits into one problem or several problems
• Organize by anatomic location, age, timing of sx

Question 4

Step 2: Data Synthesis and PROBLEM representation

Answer 4

Problem representation: a clinician’s evolving sense of the clinical picture
- Aka: Summary Statement

Includes:
- Epidemiology: demographics, risk factors, age
- Key findings: symptoms, PE + Hx. results of diagnostic testing
- Important qualifying adjectives: SEMANTIC QUALIFIERS (qualifying adjectives)

Question 5

Step 3: Generating DDx; Illness script -> what are illness scripts

Answer 5

Use illness scripts: patterns of clinical characteristics, to match patient problems with known disease presentations.
- Prioritize the most likely DDx that considers the pt demographic and the statistical probability of ds
- Always include potentially life threatening ds to r/o based on findings and pt assessment

Novice illness scripts:
- prototypical or textbook characteristics
Experienced clinician:
- more refined
– clinical characteristics trigger a memory response to the clinician’s previously learned information

Question 6

what do illness scripts include

Answer 6

Epidemiology
Pathophysiology
Time course: acute vs insidious
Clinical presentation: chest pain
Diagnostic tests

EDC PT: EDC is in Pacific Time
- Epidemiology
- Diagnostic tests
- CLINICAL PRESENTATION
- Pathophysiology
- Time course

Question 7

VINDICATE:

Answer 7

Vascular
Infectious
Neoplastic
Drug related
Inflammatory/Idiopathic/Iatrogenic
Congenital
Autoimmune/Allergic
Trauma/Toxic
Endocrine/Metabolic

Question 8

Anchoring Bias + Availability Heuristic

Answer 8

Anchoring Bias:
-Fixating on initial features too early and not adjusting with new info
- ex: A clinician sticks to a migraine diagnosis despite signs suggesting increased intracranial pressure.

Availability Heuristic
- Believing a diagnosis is likely because it comes to mind easily
- ex: After seeing many appendicitis cases, a clinician overlooks ovarian torsion in a patient with similar symptoms.

Question 9

Confirmation Bias + Diagnostic Momentum

Answer 9

Confirmation Bias
- Looking for evidence to support a diagnosis, ignoring contrary info
- ex: A clinician insists on an upper respiratory infection diagnosis, disregarding signs that suggest pneumonia.

Diagnostic Momentum
- Sticking with a previous diagnosis made by prior clinicians, ignoring alternative explanations
- ex: A clinician maintains an acid reflux diagnosis, not considering a heart attack in a patient with similar new symptoms.

Question 10

Framing Effect

Answer 10

Being swayed by how the patient’s issue is presented

Question 11

Representation Error

Answer 11

Does not take prevalence into account when estimating the probability of the dx

• ex: clinician who often sees diverticular bleeds in older pts puts it high on their DDx on a younger pt with rectal bleeding

Question 12

Visceral Bias

Answer 12

Allowing negative/positive feelings towards the patient to affect diagnosis

ex: A clinician assumes a homeless patient can’t manage complex treatment and doesn’t offer them a full range of care options.

Question 13

Step 5: Documentation of Assessment and Plan what must be included

Answer 13

• MUST ALWAYS ADDRESS HEALTH MAINTENANCE
• address social factors that impact health
• Includes new symptoms/CC first but also includes old DDx/chronic conditions assessment + plan

Question 14

Summary Statement: in assessment + plan

Answer 14

2-3 sentences
CC placed in context of pt overall health status
Includes pertinent parts of Hx, PE, and lab data
Contains semantic qualifiers

Question 15

Assessment and Plan: what is included

Answer 15

• Follows the summary statement, listing all the patient’s issues addressed during the encounter.
• Each listed problem is described with an associated differential diagnosis and an explanation of the findings supporting that diagnosis.
  The plan outlines the next steps:
• further testing
• treatment

Question 16

Problem List:

Answer 16

• Includes both newly identified and previously known conditions.
• Should note any social factors that may influence the patient’s health, like food or housing insecurity.
• The problem list should be ordered in a way that reflects the prioritization of issues, often with the chief complaint at the top.
• It should be followed by a plan for addressing that problem