1. FACULTY OF MEDICINE MALANG ISLAMIC UNIVERSITY
CLINICAL REASONING
FACULTY OF MEDICINE
MALANG ISLAMIC UNIVERSITY

2. Clinical Diagnostic Reasoning
Patient story
Knowledge
Data
Problem representation
Context
Hypothesis
Illness script
Diagnosis
Experience

3. Promote diagnostic reasoning:
Experience
Articulate problem representation
Prioritize and justify diagnostic possibilities
Develop illness scripts/disease concepts

4. Key Elements Of Clinical Diagnostic Reasoning

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

6. 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

7. 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

8. 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

9. 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

10. 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

11. Illness Script: Gout

12. Ascending Cholangitis
Illness Script
Syndrome: Right Upper Quadrant Pain
Disease
Ascending Cholangitis
Cholecystitis
Acute Hepatitis B
Epidemiology
Temporal Course
Syndrome Description

13. Spontaneous Pneumothorax
Illness Script
Syndrome: Acute Chest Pain
Disease
Angina
Pulmonary Embolus
Spontaneous Pneumothorax
Epidemiology
Temporal Course
Syndrome Description

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

15. 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

16. 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

17. 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

18. Thank you