Clinical Diagnostic Reasoning Bisatyo Mardjikoen Universitas Islam Negeri Syarif Hidayatullah Fakultas Kedokteran & Ilmu Kesehatan Program Studi Pendidikan Dokter

Case Presentation Patient’s story (male, 54 yrs): “My left knee hurt me so much last night. I woke up from sleep. It was fine when I went to bed. Now it’s swollen. It’s the worst pain I’ve ever had. I’ve had problems like this before in the same knee, once 9 months ago and once 2 years ago. It doesn’t bother me between times.”

Key Elements Of Clinical Diagnostic Reasoning

Data Acquisition Based on knowledge, experience, and other important context Elements: –History, –Findings on physical examination, –Results of laboratory testing and imaging studies

Problem Representation The way to translate a presentation of symptoms and signs into a coherent clinical case Transformation of patient-specific details into abstract (medical) terms, using semantic qualifiers, in one- sentence summary Clinicians may have no conscious awareness of this cognitive step The problem representation, unless elicited in the teaching setting, is rarely articulated

Semantic Qualifiers Paired opposing descriptors that can be used to compare and contrast diagnostic considerations Associated with strong clinical reasoning  help the doctors sort through differential diagnoses Several implied pairs when considering hypotheses for a diagnosis of gout: –multiple (not single), –discrete (not continuous) episodes, –abrupt (not gradual) onset, –severe (not mild) pain, – single joint (not multiple joints) Problem representation: acute onset of a recurrent, painful, monoarticular process in an otherwise healthy middle-aged man

Illness Script The way the clinical experience and knowledge stored in memory Storage Strategy of Experts Problem representation trigger clinical memory, permitting the related knowledge (illness script) to become accessible for reasoning

Illness Script: Key To Pattern Recognition Generated by reading and by experience Has a predictable structure: –predisposing conditions, –pathophysiological insult, –clinical consequences Another structure: –epidemiology, –temporal pattern, –syndrome statement Content: those elements which distinguish among like diseases

Illness Script The defining and discriminating clinical features of a disease, condition, or syndrome become "anchor points" in memory Defining features: descriptors that are characteristic of the diagnoses Discriminating features: descriptors that are useful for distinguishing the diagnoses from one another

Illness Script: Gout

Illness Script DiseaseAscending Cholangitis CholecystitisAcute Hepatitis B Epidemiology Temporal Course Syndrome Description Syndrome: Right Upper Quadrant Pain

Illness Script DiseaseAnginaPulmonary Embolus Spontaneous Pneumothorax Epidemiology Temporal Course Syndrome Description Syndrome: Acute Chest Pain

Defining & Discriminating Features Of A Set Of Diagnostic Hypotheses: Acute Arthritis

Pattern & Probabilities: Hypothetico-Deductive Reasoning The strategy of generating a hypothesis early in the reasoning process,and then seeking out information to prove or disprove their theory before moving on to a different hypothesis if necessary The model of a combined non-analytical strategy (pattern recognition) with a more analytical phase (checking key features of the proposed diagnosis) are effective and used simultaneously, in interactive fashion

Pattern & Probabilities: Hypothetico-Deductive Reasoning Pattern recognition: –essential to diagnostic expertise –this skill is developed through clinical experience Deliberative analytic reasoning is the primary strategy when: –a case is complex or ill defined, – the clinical findings are unusual, –the physician has had little clinical experience with the particular disease entity

Pattern & Probabilities: Hypothetico-Deductive Reasoning The difference between novices and experts: –the speed & accuracy of the hypotheses made, –the method and efficiency of weighing up evidence for and against the hypothesis Some of this speed lies in the ability to recognise patterns Some areas of medicine rely heavily on pattern recognition

References 1.Bowen JL. Educational strategies to promote clinical diagnostic reasoning. Med Educ 2006;21: Eva KW. What every teacher needs to know about clinical reasoning. Med Educ 2005;39: Norman G. Research in clinical reasoning: past history and current trends. Med Educ 2005;39: Coderre S, Mandin H, Harasym PH, Fick GH. Diagnostic reasoning strategies and diagnostic success. Med Educ 2003;37: Nendaz MR, Bordage G. Promoting diagnostic problem representation. Med Educ 2002;36:

References 6.Elstein AS, Schwarz A. Clinical problem solving and diagnostic decision making: selective review of the cognitive literature. BMJ 2002;324: Koens F, Mann KV, Custers E, Ten Cate OT. Analysing the concept of context in medical education. Med Educ 2005;39: Stone L. Reasoning for registrars. AFP 2008;37(8): Amjad A. Clinical diagnostic reasoning and the curriculum: a medical student’s perspective. Medical Teacher 2008;30: Lucey CR. From problem list to illness script (cited 2009 Sept 8). Available from: URL: HYPERLINK 03Archives/scholars0203/PLtoILLgroups.pdf 03Archives/scholars0203/PLtoILLgroups.pdf

Simulasi Kasus

Pertanyaan 1.Sebutkan 2 pertanyaan yang penting anda ajukan pada anamnesis? 2.Sebutkan 2 macam pemeriksaan fisik yang penting anda lakukan? 3.Sebutkan 3 diagnosis banding yang paling mungkin terjadi pada kasus ini? 4.Sebutkan 2 jenis pemeriksaan penunjang yang perlu anda lakukan?

Kasus 1 Nn A, perempuan, 24 tahun, datang ke poliklinik dengan keluhan nyeri ulu hati sejak 2 hari yang lalu.

Kasus 2 Tn C, laki-laki, 60 tahun, datang ke tempat praktek anda dengan keluhan kencing berwarna merah sejak 4 hari yang lalu.

Kasus 3 Ny D, perempuan, 45 tahun, datang ke IGD dengan keluhan nyeri perut kanan atas sejak 2 jam yang lalu.

Kasus 5 Tn E, laki-laki, 56 tahun, datang ke IGD dengan keluhan nyeri dada kiri sejak 30 menit yang lalu.

Kasus 6 Ny F, perempuan, 48 tahun, datang ke poliklinik dengan keluhan batuk sejak 6 minggu yang lalu.

Kasus 7 Ny G, perempuan, 55 tahun, datang ke IGD dengan keluhan dada berdebar-debar sejak 30 menit yang lalu.