CSS:

DEVELOPING CLINICAL PROBLEM-SOLVING SKILLS

Clinical Reasoning Process
Model for approaching a clinical case
Similar to detective work, e.g. CSI
Problem presents without a clear cause
A number of causes can be entertained
Causes generate hypotheses for the problem
Finding the correct hypotheses or cause
requires
o Information on causes
o Interview of witnesses or history of
patient
o Search for clues or physical examination
o Clues go beyond what is before you
o History and PE and laboratory and
diagnostic procedures are varied
As more information is gathered by detective, it
supports or negates a theory or a suspicion
about the crime
As more information is collected, hypotheses
change regarding the diagnosis
A poor match in the hypotheses may evolve
leading to a change in hypotheses

Patients Problem
Initial set of information is not sufficient for a
diagnosis
No one correct or prescribed way to get this
information
Information collected will eventually arrive to
the same diagnostic conclusion
Ill-structured problems
No definite guidelines for working up the
problem
Ambiguities and conflicting or inadequate
information the rule in medicine
Patients problem constantly changing
No assurance of the solution to the problem
Only confident of approaching a solution

Initial Information
The nurse refers Mr. Santos, a 55 y.o. man, who
presents in the ER with chest pain of 6 hours
duration
THINK OF:
o What questions will you ask of the
patient?
o What initial PE findings would you be
interested in verifying?

Initial encounter
Chief complaint, comments, response to your
questions
Appearance, age, sex, physiognomy, posture
Movements, speech characteristics (animation,
clarity, rise and fall of voice)
Appearance and manner of companions

Information to be given by preceptor at the start:
Looks his age, overweight, almost obese,
casually dressed, sweating in an aircon room
Not in distress, sitting on examination table,
bent forward, hands grasping edge of bed
Speech clear, with anxious tone
Complains of persistent chest pain
Brown stains on 2nd and 3rd fingers right hand,
smells of alcohol

Your next steps
What is your INITIAL CONCEPT?
What are you considerations?

Initial encounter
Patient information available at the start of encounter

Perception

Analysis

Initial concept

CSS Lecture Notes: DEVELOPING CLINICAL PROBLEM-SOLVING SKILLS [by: mee-shell ]

Initial Concept
A more refined statement of the patients
problem from the doctors perspective
1-2 sentences
Incorporates your information from the initial
encounter
If you have any possible ideas of the patients
problem. Look for evidence that supports or
refutes your ideas.
Not necessarily your final clinical impression or
diagnosis
o Middle-aged male with chest
symptoms, with indicators of increased
risk
factors
for
cardiovascular
problems
Carefully search for all information you can
gather
Determine usefulness of any observations made
by other people accompanying patient
Determine if patient implying something other
that what was expressed verbally
Determine the patients attitude towards you
and your encounter

Clinical Reasoning Process

Patient
Information

Inquiry
Strategy

Problem
Synthesis

Multiple
Hypotheses

Next: Generate GENERAL HYPOTHESIS
Based on the initial concept, what are likely
categories where your eventual primary
working impression will belong to?





2

Clinical Hypothesis
Generated from patients problem
Different clinical possibilities when information
is inadequate
Requires an inquiry strategy to obtain the
appropriate facts
o Guided by clinical hypotheses
New information is synthesized into hypotheses

Hypothesis
Initial hypothesis BROAD
In anatomic and physiologic terms
o Visceral chest pain of cardiovascular
origin
o Parietal chest pain (musculoskeletal or
pleuritic)
o Psychogenic pain
When complaint too vague or broad, narrow
down hypotheses by asking more questions

Diagnoses
Appendicitis
Myocardial Infarction
Peptic ulcer
Pneumonia

Syndromes
Menires syndrome
Preeclampsia
AIDS

Pathophysiological entities
Seizure disorder
Hypertension
Angina

Pathophysiologic concepts
Hyponatremia
CHF
Demyelinating disease

Anatomic entities
Lateral meniscus tear
Parenchymatous liver disorder
Retinal dysfunction

CSS Lecture Notes: DEVELOPING CLINICAL PROBLEM-SOLVING SKILLS [by: mee-shell ]

Etiologic processes
Viral infection
Drug toxicity
Nutritional deficiencies
Degenerative disease

Psychological or social issues
Conversion reaction
Dysfunctional family
Marital discord
Malingering

Starting the inquiry
Ask broad open-ended questions that will allow
the patient to give you raw data unaffected by
leading cues and biases of the interviewer
Specific questions follow later for areas not
covered

Designing Inquiry Strategy
Analysis and Synthesis
o Analysis new data obtained from Hx
and PE of value to support or negate
the hypotheses
o Date of value are synthesized into initial
concept
Deduction process of gathering date from Hx
and PE to separate, support of weaken your
hypotheses

Generating and regenerating hypotheses
Hypotheses generated from initial concept
Creative process; brainstorming
As inquiry continues, hypotheses may be
eliminated and replaced by new ones
If hypotheses are not eliminated during the
inquiry, the strategy is inefficient
Hypothesis are not changed or modified; these
are eliminated

Clinical Reasoning Process

Patient
Information
Perception
Analysis

H1

Initial
concept

Multiple
Hypotheses

Inquiry
Strategy

H2

H3

Clinical Reasoning Process

H3.1 H3.2

H1

Initial
concept

H2

H3

Multiple
Hypotheses

AVOID Disengaged Inquiry
Student produces a good set of hypotheses but
inquiry strategy does not lead to analysis and
synthesis by deduction
Inquiry strategy follows the standard by the
book approach wasting precious time

DO THIS: Search
Directed inquiry
Hypotheses-oriented or problem-oriented
activity
Information is sought to resolve the hypotheses
entertained

CSS Lecture Notes: DEVELOPING CLINICAL PROBLEM-SOLVING SKILLS [by: mee-shell ]

FOLLOW UP WITH: Scan

Non-hypotheses oriented inquiry routine
Background, demography, review of systems,
screening questions
Covers gaps left in the inquiry process
Can lead to new ideas and approaches
Buys time and confidence
Allows clinician time to get to know the patient
and his/her environment

THE GOAL: Efficiency
Efficiency is necessary in the inquiry strategy
The object of efficiency is to arrive at the clinical
impression or working diagnosis in the shortest
period of time
Use reasoning, the facts available, facts from
basic science and the pathology
Review your strategy to learn from your
approach

Applying Appropriate Clinical Skills
90% of your diagnosis is dependent on a good
medical history
P.E. is used to confirm your what you have
decided is your impression in your history
Lab exams are used to further discriminate your
primary impression from your differential
diagnosis

Clinical Reasoning
Clinical reasoning process is the same for every
case
Facts of each case vary
Knowledge requirements for each case varies
Most efficient manner of gathering information
comes with experience
o Little cues and variations in clinical
complaints
o Slight variations in the patients clinical
presentation and P.E.
Will carry physician a long way even if one is
short of needed facts.

Clinical Reasoning Process

Patient Information

Tests

Perception

Clinical
Skills

Inquiry
Strategy

Analysis
Problem
Synthesis

Behavior
Modification

Rational
Behavior
Compliance

Multiple
Hypotheses

Diagnostic
Decision
Therapeutic
Decision

CSS Lecture Notes: DEVELOPING CLINICAL PROBLEM-SOLVING SKILLS [by: mee-shell ]

Patient
Education