CLINICAL

REASONING
dr. Rahma Triliana, S.Ked. M.Kes

CLINICAL REASONING
IS
THE MOST ESSENTIAL
SKILL NEEDED TO
PRACTICE MEDICINE

Clinical Reasoning Leads to

Decision-Making

How do clinicians use their

knowledge to arrive at
diagnostic and management
decisions?

Clinical Reasoning and

Decision-Making
(Bordage, G. Academic Medicine, 1994, 1999)

Reduced
Dispersed

(empty mind)

Elaborated
Compiled

(deductive thinking)

(cluttered mind)

(recall/recognition)

What do we know about clinical

reasoning and decision-making?

Effective reasoning and decision-making is

knowledge dependent
Competent clinicians use deductive reasoning
(elaborated thinking) or recall/recognition
(compiled thinking)
Expertise is case/problem specific (central role of
knowledge)
Thoroughness of data gathering is unrelated to
diagnostic accuracy; compiled clinicians focus on
only key issues

CLINICAL REASONING,
ASSESSMENT & PLAN
Detailed

History taking & Thorough physical

exams
Analyze & Identify problems that needed to
be solved
Form an assessment
Plan your action
Record

BASIC SKILL NEEDED

Enough

Knowledge of Medicine
Analitical/Logical Thinking Abitilty to
reason
Curiousity
Thoroughness (in certain occation)
Open Mind Accept any possibility
For the Greater Good

CLINICAL PROCESS
S = Subjective = History taking (patients or family)
O = Objective = Physical exam & laboratory test

Make up the core elements based on factual & descriptive result of

patients

A = Assesment = Analysis & interpretation = clustered relevant

information, analyze possible meanings, logically explain with
medical science (pathogenesis)

P = Plan intervention (patient response, good interpersonal skill,

sensitivity to patients goal, economic, responsibility, family
structure & Dynamics)

Record fasilitate critical thinking, communication & coordination with

other health care professionals, document patients problems &
progress & medicolegal purposes.

HOW TO REASON CLINICALLY

To

practice think at the beginning of

patient encounters
Focus on finding answers to;

- Whats wrong with this patient?

- What are the problems and the diagnosis?
Do

Steps in Clinical Reasoning (identify

problems & making diagnosis)

BEGINNING OF PATIENT
ENCOUNTERS
Try

Asking Patient in This Step

- Whats wrong with you? Complaint/s

- Where do you feel it? Location/Anatomy
- When did it happen? (Onset & duration) Time
- How did It happen? Suspected Mechanism
- What relieve/aggreviate it? Involving factors
Think

on

- Why the problem Occurs in this patient?

-

Pathogenesis
What is the diagnosis? Treatment & Plan

PRACTICE

STEPS of CLINICAL
REASONING
Identify

Abnormal Findings
Localize findings anatomically
Interpret findings in term of probable process
Make hypotheses about the nature of
patients problem
Test The hypotheses & establish a Working
Diagnosis
Develop a plan agreeable to the patients

IDENTIFY ABNORMAL FINDINGS

Make

symthoms List
Make signs list
Plan laboratory test needed (begin with basic
lab e.g. CBC, urinalysis, Liver Function Test,
& Renal Function Test)
Make list of abnormal laboratory findings
Make additional laboratory test if needed

LOCALIZE FINDINGS
ANATOMICALLY

Place the simpthoms or sign in local or regional area

anatomically.
e.g. Diarrea may be GIT problems,
Cough may be due to thorax problem
Careful with symthoms and sign that can be
interpret for many human body systems
Set a local body region or system region
If the sign cant be localized (e.g fever, fatique,
malaise), try to make clustered data that help to
select most probable cause of disease

INTERPRET FINDINGS IN TERM

OF PROBABLE PROCESS
Identify

Pathological process involving a

disease of a body structure
Classify to : Congenital,
Infection/inflammation, Immunologic,
Neoplastic, Metabolic, Nutritional,
Degenerative, Vaskular, Traumatic, and Toxic
Consider pathophysiologic &
Psychopathologic

MAKE HYPOTHESES ABOUT THE

NATURE OF PATIENTS PROBLEM

Draw all your knowledge & Experience (Read again if you must)
Find Patterns of abnormalities & disease then cluster them with
your patients
Use evidence-based-decission making COMMON THINGS
ACCURS COMMONLY
Select the most spesific & critical findings to support your
hypothesis
Match your findings with againts all the conditions you know that
can produce them
Eliminate the diagnostic possibility & select the most likely
diagnosis (consider epidemiological study)
Give special attention to potentially life threatening & treatable
conditions & always include The WORST Case scenario in
your list of diagnosis & DD

TEST YOUR HYPOTHESES

Asked

Further History
Additional maneuvers on physical exams
Other Laboratory studies
Radiologic test to confirm or to rule out
tentantive diagnosis
For simple cases (out patients management,
this and onward steps may not be necessary)

ESTABLISH A WORKING
DIAGNOSIS
Mention

your diagnosis based on abnormal

structure (e.g. hepatomegali), altered process
(e.g. hypertension), or spesific cause (e.g
blunt trauma)
Identify other things that relate to patients life
& health
Plan Health maintence (Patients education to
maintain & increase health level)

DEVELOP A PLAN AGREEABLE

TO THE PATIENTS
Identify

& record plan for patient (diagnostic,

theraupetic & education)
Confirmation tests or evaluate further
diagnosis
Consultations to specialist or subspecialist
Addition, deletions or changes in medications
Share with your patients & seek their opinion,
concern and willingness to establish good drpatients relation)

THERAPY AS A SCIENCE
Decission

Making in regards to patients

treatments
Based on diagnosis process & clinical
reasoning
Science in giving medication evidence
based medicine & Clinical Trials
Can be Psychologic, Sosial/family,
Behaviour/life style changes, Pharmacologic
or Surgery treatments

EG. Case I
Ny I, 35 tahun, datang dgn keluhan demam, BAK
nyeri (Disuria), rasa tak tuntas saat berkemih (Anyanganyangen) dan nyeri pinggang. Ia juga mengeluh mual,
namun tidak muntah. BAB tidak ada keluhan, & menstruasi
terakhir tgl 16-08-07
Hasil pemeriksaan fisik; Tensi 120/80mmhg, Nadi
80x/min, reguler, kuat. RR 18x/min & T.Ax = 38,9oC. KU
lemah & anemis, Kepala, leher, thorax, & extremitas tidak
ditemukan kelainan. Pada abdomen didapatkan peningkatan
bising usus, pembesaran uterus setara kehamilan 14 16
minggu, dan nyeri tekan supra pubik. Flank pain dan flank
mass tidak didapatkan

S : Demam, Disuria, Anyang-anyangen/urgensi, nyeri pinggang,

mual (+), muntah (-). BAB taa, & HPHT 16-12-07
O: Vitals = T : 120/80, N: 80x,
RR : 18x,
T.Ax = 38,9oC.
KU= lemah, kesadaran Compos mentis
Kepala = anemis +/+, Icteric -/-, edema palp -/Leher = Tyroid & trachea dBN, Pembesaran Lnn Leher (-)
Thorax = Bentuk normal,
Cor = Ictus cordis visible but not palpable
RHM = ICS IV, SL Dex. LHM = ICS V, MCL Sin
S1-S2 tunggal, Murmur (-)
Pulmo = Rh -/- wh -/Abdomen = Bising Usus + (),
Hepar = tidak teraba, Lien = Tidak teraba
Uterus palpabel 3 jari atas symphisis pubis (14 16 minggu)
Nyeri tekan suprapubik
Flank Pain - / -, Flank Mass - / Extremitas = Atas: Motoris +5 / +5 Sensoris N / N Edema -/Bawah: Motoris +5 / +5 Sensoris N / N Edema -/-

O : Wdx: Cystitis + Amenorhea

dd: Uretritis
Pielonephritis
Glomerulonephritis

P : Dx : DL, UL, Ureum Creatinine, Uric Acid, SGOT, SGPT.

Kultur urine
USG Abdomen
Plano test
Tx : MRS
Infus D5% : RL = 25 tetes/menit
Amoxicillin 3 x 1 gr IV (test dulu)
Novalgin 3 x 1 amp IV, Prn panas
Farbion 3 x 1 amp IM
Tirah baring
Observasi VS / 4 jam
diet TKTP
KIE keluarga

Clinical Reasoning
Is Not Something That
You Can Achieve
Overnight But Its A
Results Of Simple
Means Of Commonsense & Perseverance

 The

significance of a man is not in what he

attains but in what he longs to attain. (Kahil
Gibran)
We are what we repeatedly do.
Excellence, therefore, is not an act but a
habit. (Aristotle)
It does not matter how slowly you go so long
as you do not stop.
Confucius
We are still masters of our fate.
We are still captains of our souls.
(Winston Churchill)