Clinical reasoning in Medicine

1. Teaching Clinical Reasoning Skills
(Clinical Decision Making)
‫الاكلينيكية‬ ‫الحالات‬ ‫فى‬ ‫المنطقى‬ ‫التفكير‬ ‫مهارات‬

3. A word of caution!
Teaching reasoning skills is not a method to help
students acquire knowledge
But
A framework to help students reorganize their
previously acquired knowledge for clinical
reasoning.

5. Clinical reasoning is a skill to be learnt,
not unlike driving a car.

6. Objective (In One word!)
To teach students how to move efficiently from patient
symptoms and signs
To
a rational and prioritized set of diagnostic possibilities

7. Clinical Reasoning
“If you don’t know where you are going,
you might end up someplace else”

8. Why is Clinical Reasoning Important?
• Diagnostic errors are common.
• Two‐thirds of the causes of diagnostic error
involve errors in reasoning, most commonly
when the available data are not synthesized
correctly.

9. What is the Problem?!
• The practice of medicine would be simple if
each symptom or sign indicated a single
disease!
• There are enormous numbers of symptoms
and signs and they can occur in a nearly
infinite number of combinations and temporal
patterns.

10. Steps to reach diagnosis
• Medical History
• Physical examination
• Data Interpretation
• Differential Diagnosis
• Diagnostic studies

11. Developing Clinical Reasoning
• It is important to remember that, to develop
clinical reasoning, the final answer is less
important than the process leading to
clarifying the problem.
• The student may well find a good answer but
have incorrect reasoning. This is the important
concept of allowing students to “think aloud”.

12. The ‘Language’ of
Clinical Reasoning

13. Clinical Reasoning Process
1. Data-Gathering
2. Semantic qualifiers & Problem representation
3. Adopt a framework
4. Illness scripts
5. Compare and contrast
6.Prioritize the differential diagnosis

14. Key elements of clinical diagnostic reasoning
1. Data collection (history, physical
examination, and the results of diagnostic
testing).
2. Creation of a “problem representation,”
usually as a one-sentence summary using
semantic qualifiers.

15. Semantic qualifiers

16. Semantic qualifiers
• It translates the patient’s data into medical
terms.
• For example, one day becomes acute;
• chronic daily use of 20mg of prednisone
becomes immunocompromised;
• left ankle pain and swelling become
monoarticular arthritis; and
• fever, tachycardia, and leukocytosis become
inflammatory.

17. Semantic qualifiers
• Translating lay language into medical
terminology enables easier access to the
knowledge stored in the one’s illness scripts.
• By comparing and contrasting opposing
diagnostic features, these abstract semantic
qualifiers (e.g. acute vs. chronic, dull vs.
sharp, distal vs. proximal) add differentiating
power to a problem representation.

18. List of Semantic qualifiers
• Acute – chronic
• Sudden – gradual
• Immediate - delayed
• Constant - intermittent
• Unilateral – bilateral
• Left-sided – right-sided
• At rest – with activity
• Painful – painless
• Exudative –
nonexudative
• Productive –
nonproductive
• Tender – non-tender
• Mild – severe

19. Semantic Qualifiers/Problem Representation
• “Last night” became “acute onset,”
• “I’ve had problems like this before” became
“recurrent,”
• “same knee” became “monoarticular,” and
• The patient’s age, sex, and medical history
are summarized as “otherwise healthy,
middle-aged man.”

20. Simply, translating the patient’s story

21. Problem Representation
(Case Formulation)

22. Problem Representation
• A one-sentence summary that highlights the
defining features of a case.
• It helps clinicians summarize their thoughts
and then generate a differential diagnosis.
• A well-formed problem representation
facilitates clinical reasoning and serves as
backbone for how clinicians communicate
with one another.

23. Features of Good Problem Representation
• Should answer three questions:
1. Who is the patient? Pertinent demographics and
risk factors
2. What is the time course of illness?
Onset/Duration (hyperacute, acute, subacute, chronic) and
Course (stable, progressive, resolving, intermittent)
3. What is the clinical syndrome? Key signs and
symptoms

24. Patterns of Onset and Course of
Neurologic Conditions/ Pathophysiology

25. Consider the following case
• A 60-year-old woman with rheumatoid
arthritis presents with one day of left ankle
pain and swelling as well as one week of
malaise. She has been on prednisone 20mg
daily for the past 6 months. On exam, she is
febrile and tachycardic, with left ankle edema,
erythema, and tenderness with active and
passive range of motion. Blood work is
significant for a WBC of 15000.

26. A concise/brief problem
representation
• A 60-year-old immunocompromised woman
presents with acute monoarticular
inflammatory arthritis.

27. • A 60 year old immunocompromised woman
(Q1Who is the patient) presents with acute
(Q2What is the time course) monoarticular
inflammatory arthritis (Q3What is the clinical
syndrome).

28. A less concise problem representation
• A 60-year-old woman with rheumatoid
arthritis presents with ankle pain and swelling
in the setting of malaise, with exam significant
for tachycardia, fever, left ankle arthritis, and
leukocytosis

29. Key elements of clinical diagnostic reasoning
3. Adopt a framework
• Anatomical (organ based)
– Chest pain (cardiac, pulmonary, hematologic)
– abdominal pain,…
• Physiologic
– Acute renal failure (prerenal, intrinsic, postrenal)
– Anemia (Decreased production, increased
destruction)
• Etiological (VITAMIN CC&D)

30. VITAMIN C C & D
V ascular
I nfections & intoxications
T rauma & toxins
A uto-immune
M etabolic
I diopathic & iatrogenic
N eoplastic
C ongenital
C onversion (psychiatric)
D egenerative

31. Key elements of clinical diagnostic reasoning
4. Illness script:
The problem representation activates illness
scripts, mental representations of potential
diagnoses, within the clinician’s memory.
A summary of a diagnosis including:
• Predisposing factors
• Pathophysiology
• Clinical findings

32. Example (a)
Pulmonary thromboembolism
• Predisposing factors
– Post-orthopedic procedure
• Pathophysiology
– Compression/ stasis, venous thrombosis,
pulmonary infarct
• Clinical findings
– Dyspnea, tachypnea,…

33. Example (b)
1. 16-year-old boy.
2. Admitted for acute abdominal pain.
3. Has poor PO intake.
4. Pain started around his umbilicus but has
moved to the RLQ.
5. Febrile to 39.4°C.
6. Has associated nausea, vomiting, and
anorexia.

36. Acute appendicitis

37. Example (c)
1. 8-year-old boy
2. Admitted for acute abdominal pain
3. Has poor PO intake for the past day
4. Has a purpuric rash in a waist-down
distribution
5. Presents with large joint pain
6. Has proteinuria on urinalysis

40. Henoch-Schonlein Purpura (HSP)

41. 5. Compare and contrast
• The student learns features common to both
and which features favor one condition over
another
• The illness script for pneumonia differs from
that for congestive heart failure in the
constellation of features, despite some
overlap.

42. Compare & Contrast

43. Clinical Reasoning Process
1. Data-Gathering
2. Semantic qualifiers & Problem representation
3. Adopt a framework
4. Illness scripts
5. Compare and contrast
6.Prioritize the differential diagnosis

44. One Teaching Model
Levin M et al. 2016. Teaching Clinical Reasoning to Medical Students: A Case-
Based Illness Script Worksheet Approach. MedEdPORTAL. 2016;12:10445

45. Methods of Teaching/Assessment of
Clinical Reasoning Skills
1. Patient Note Form
2. Comprehensive Integrative Puzzle (CIP)
3. Compare and Contrast
4. Key Feature Problems
5. Script Concordance Test
6. Extended Matching Questions

46. Thank You!