National post graduate college reasoning format

1. Clinical Summary and Reasoning
Format in Practice
Dr. Fidelis Njokanma FMCPaed.
February, 2017

2. About Clinical Reasoning
• the cognitive process that is necessary to
evaluate and manage a patient’s medical
problem’.
• It is the summation of thinking and/or decision-
making processes that are used in clinical
practice
• A major determining factor of clinical competence
• We have all been practising clinical reasoning from
the earliest days of medical school

3. About Clinical Summary
• Summary:
– A distillate
of pertinent information
from a larger mass of data.

4. Format:
–A predesigned style of
presenting information

5. In brief:
• What I present to you today, is a
predesigned style of presenting a
distillate of pertinent information on
patients that helps to track the cognitive
process necessary to evaluate and
manage a patient’s medical problem’.

6. Sections of the CSRF
• Patient-derived information
• Conclusions from patient-derived information

7. Patient-derived information
–History
–Physical examination
–Investigations

8. History
• A patient's history reveals a lot of information -
some of which are symptoms of disease and
others which although do not constitute
symptoms may be required in making a
diagnosis or in planning intervention.

9. Symptoms
• Presenting Complaints
• History of Presenting Complaints
• Review of Systems.

10. Other useful information
• Identification data (age, sex, religion, address)
• Drug history
• History of Past Illnesses
• Pregnancy/Birth History
• Vaccination history
• Growth and Developmental history
• Family and Social History.

11. Still on patient-derived information
• Physical examination yields signs which
may be indicative to the patient's current index
illness or may be tell-tale features of a present
or past disease or intervention/treatment
• Available results of Investigations provide
information on the patient from a laboratory
point of view.

12. Conclusions from patient-derived information
• Identify the diseased system(s)
• Identify the Pathologic Process(es) involved
• Distill Functional and/or Structural Abnormalities
• Propose a provisional diagnosis
• List required investigations
• Propose the Pathologic diagnosis
• Name the Aetiologic diagnosis

13. The Faculty has adopted an 8-system approach:
• Central Nervous System
• Musculoskeletal System (including the integumen)
• Cardiovascular System
• Respiratory System
• Digestive System
• Urogenital System
• Haematologic System
• Endocrine System

14. Pathologic process – definitions
• A biologic function or a process having an
abnormal or deleterious effect at the subcellular,
cellular, multicellular, or organismal level.
• The abnormal mechanisms and forms involved in
the dysfunctions of tissues and organs
• An organic process occurring as a consequence
of disease
• The fundamental biologic derangement
underlying a disease

15. 9 processes have been chosen from a myriad
• Inflammation
• Immunologic derangement
• Ischaemia
• Degeneration
• Dysgenesis
• Deranged Metabolism
• Lysis
• Neoplasm
• Trauma
Fortunately, these are terms with which
we are all familiar

16. Functional abnormality
• An observable or discernible alteration of body
function.
• Symptoms and signs may actually represent
abnormalities of function e.g. fever, cough, easy
fatigability.
• Sometimes a conglomeration of symptoms and signs
may point in a particular direction in which case a
group name may be used e.g. respiratory distress in
a case where there are flaring alar nasi, intercostal
and subcostal recession.

17. Structural abnormality
• Observable or discernible alteration of a tissue or
organ in terms of colour, contour, content,
consistency, shape or size – i.e. deranged anatomy.
• Structure and function are intimately related
• Therefore, abnormal structure is to be expected to
be related to abnormality of function.

18. For example:
–Presence of central cyanosis (structural
abnormality) bespeaks poor oxygenation
(functional abnormality).
–Presence of post-burns contracture of the
elbow joint (structural abnormality) leads to
limitation of movement across that elbow
(functional abnormality).

19. Some facts to remember:
• there may be more than one functional and/or
structural abnormality
• it may not be feasible in EVERY case to make a
functional as well as a structural diagnosis - one OR
the other may be found
• the same or similar words may occur from one
stage of the CSRF to the other. For instance, it may
happen that fever is the major symptom, the only
sign, the functional abnormality and thus the
functional diagnosis will be "febrile illness".

20. Pathologic diagnosis
• Symptoms and signs have been analyzed, diseased
systems and pathologic process(es). Identified
• Conclusions have been drawn at
functional/anatomic levels.
• It has been stated that all the conclusions so far
MUST be incontrovertible.
• Noting that functional and anatomic diagnoses may
have many factors to explain their presence
• The first stage of that explanation is to make a
pathologic diagnosis.

21. Pathologic diagnosis – 2
• Interestingly, this is the stage with which clinicians
are most familiar but without the prefix
"pathological”. Terms like meningitis,
bronchopneumonia, acute glomerulonephritis,
rheumatoid arthritis, neuroblastoma etc are all
pathologic diagnoses.
• As is obvious from clinical practice, was also stated
in earlier sections, the practice of making differential
diagnoses is inevitable here.

22. Pathologic diagnosis – 3
• This is principally because more than one
pathologic diagnosis may share signs,
symptoms and abnormalities. As a result, the
plausible conclusions at this stage are
speculative and will remain open to more than
one diagnosis until more information (usually
laboratory) is available.

23. Aetiologic diagnosis
• This section needs no elaboration.
• It qualifies the pathologic diagnosis.
• For example, if we are dealing with
bronchopneumonia, is it bacterial, viral or
fungal and indeed which particular organism?

24. Admittedly:
• The situation is not always so clear-cut.
• There are tough cases in which finding a scholarly
expression would prove quite challenging.
• It therefore the duty of clinicians to engage
constructively
• The best way is to use the CSRF over and over and
over again. The easy cases will be raced through
and the tough cases will be thought through. There
will be arguments and debates but settlement and
harmony will certainly follow.

25. Challenge:
• Write down a pathologic diagnosis
• Identify functional and/or anatomic diagnosis
compatible with the pathologic diagnosis
• Identify functional and/or structural
abnormality
• State the associated pathologic process
• Identify the system(s) with derangements
• State plausible symptoms and/or signs

26. Amen!