Clinical Reasoning

Zayadi Zainuddin, MD, M.Med.Ed

Medical Program Study
University Of Bengkulu

Clinical Reasoning
the cognitive process necessary to evaluate
and manage a medical problem
Reasoning

Skill

Knowledge

Key Element Of Clinical

Diagnostic Reasoning
Knowledge

Patient story
Data
Problem representation

Context
Hypothesis
Illness script

Diagnosis
Experience

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 onesentence 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
Syndrome: Right Upper Quadrant Pain
Disease
Epidemiology
Temporal Course
Syndrome
Description

Ascending
Cholangitis

Cholecystit
is

Acute
Hepatitis B

Illness Script
Syndrome: Acute Chest Pain
Disease

Epidemiology
Temporal Course
Syndrome
Description

Angina

Pulmonary
Embolus

Spontaneous
Pneumothora
x

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.
2.
3.
4.
5.

Bowen JL. Educational strategies to promote clinical diagnostic

reasoning. Med Educ 2006;21:2217-2225.
Eva KW. What every teacher needs to know about clinical
reasoning. Med Educ 2005;39:98-106.
Norman G. Research in clinical reasoning: past history and
current trends. Med Educ 2005;39:418-427.
Coderre S, Mandin H, Harasym PH, Fick GH. Diagnostic
reasoning strategies and diagnostic success. Med Educ
2003;37:695-703.
Nendaz MR, Bordage G. Promoting diagnostic problem
representation. Med Educ 2002;36:760-766.

References
6.
7.
8.
9.
10.

Elstein AS, Schwarz A. Clinical problem solving and diagnostic

decision making: selective review of the cognitive literature. BMJ
2002;324:729-732.
Koens F, Mann KV, Custers E, Ten Cate OT. Analysing the
concept of context in medical education. Med Educ
2005;39:1243-1249.
Stone L. Reasoning for registrars. AFP 2008;37(8):650-653.
Amjad A. Clinical diagnostic reasoning and the curriculum: a
medical students perspective. Medical Teacher 2008;30:426-427.
Lucey CR. From problem list to illness script (cited 2009 Sept 8).
Available from: URL: HYPERLINK
http://casemed.case.edu/curricularaffairs/scholars/2002-03Archi
ves/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.