GP 08 - Introduction to Clinical Reasoning

Question 1

List the key steps to clinical reasoning?

Answer 1

1. Identify the problem
2. Frame the DDx in a way that facilitates recall
3. Organize the DDx into clinically useful subgroups that enable you to systematically work through them
4. Limit the DDx by using pivotal points to create a patient-specific DDx
5. Explore the psDDx using history and physical exam findings
6. Rank the DDx - leading hypthesis, must not miss hypotheses, alternatives
7. Test the hypotheses
8. If diagnosis is confirmed, treat. If not, Rerank DDx based on new data and select and test new hypotheses until a diagnosis is reached.

Question 2

Describe the best way to go about performing step 1 of the clinical reasoining process - Identify the Problem.

Answer 2

• Utilize history taking skills to construct a complete problem list consisting of: C.C, other acute symptoms/abnormalities, chronic active problems, important past problems
• Determine onset, site, course, severity, and context (does the symptom go away at certain times) for each symptom
• Eliminate nonspecific and redundant symptoms
• Combine descriptive terms to generate a problem representation

Question 3

What is the best way to go about performing steps 2, 3, and 4 of the clinical reasoning process?

Answer 3

Use some kind of problem specific framework to organize DDxs into subcategories:

• Anatomic frameworks - commonly used for chest and abdomen pain
• Organ/System frameworks - used for symptoms with very broad DDxs
• Physiological frameworks - commonly used for endocrine symptoms

Base these frameworks on the pivotal points of the symptoms

Question 4

When exploring the psDDx (Step 5), what are some very important things to keep in mind?

Answer 4

• Focus on positive findings more than negative findings
  
  • very specific findings suggest specific diagnoses because they are rarely seen in patients without disease
  • negative findings should not be uses to rule out diagnoses because “classic” findings can often be absent

Question 5

When ranking the DDxs (Step 6), what are the common approaches to take?

Answer 5

• Possibilistic Approach - consider all known causes equally likely and simultaneously test for all of them. Not a very useful approach
• Probabilistic Approach - consider those disorders with the highest pretest probability first
• Prognostic Approach - consider the most serious diagnoses first
• Pragmatic Approach - consider the diagnoses most responsive to treatment first

Question 6

What is an illness script? Why are they useful?

Answer 6

An organized mental summary of a provider’s knowledge of a disease. It usually consists of:

• Pathophysiology - what are the biomedical causes of the disease
• Epidemiology - what populations commonly get the disease
• Temporal Course - how does it present over time
• Clinical features
• Diagnostics - what tests confirm/refute diagnosis
• Treatment

Physicians generate a patient ilness script (patient’s info) and correlate it to published pathological illness scripts

Question 7

What is horizontal reading?

Answer 7

The reading of similar/overlapping diagnoses at the same time in order to compare and contrast. This is opposed to vertical reading is just reading one diagnosis at a time. This is usually facilitated by tables.

Question 8

What is the EBM Triad?

Answer 8

The combination of the following:

1. Patient Values & Expectations
2. Individual Clinical Expertise
3. Best External Evidence