Clinical Reasoning in Clinical

Practice
Sylvia Rianissa Putri
What is Clinical Reasoning?

• The process of how we reason through data and arrive at a decision.

• Uses both medical knowledge and experience.
Clinical Reasoning

“the cognitive process necessary to evaluate and

manage a medical problem”

Reasoning

Skill Knowledge
Clinical Reasoning

• Knowledge
–Discipline specific knowledge base
• Cognition
–Thinking skills that allow clinician to process clinical
data against knowledge base
• Metacognition
–Bridges knowledge and cognition; thinking about
thinking
Knowledge
• Biomedical knowledge
• Clinical knowledge
• Increase growth of knowledge needs to be organized to be useful
Cognition
• Perception of relevant from irrelevant information
• Interpretation of information and hypothesis testing
• Inquiry strategies (hypothesis testing)
• Weighting and synthesis of information
• Metacognition: self-awareness of the thinking process
• Based on the theory that we learn more from reflecting on our experiences
than from the actual experiences themselves.
• Therapist‘s awareness, self-monitoring and reflective processes.
• Thinking about your thinking.
Hypothetico-Deductive Reasoning

• Analytic process of reasoning (Eva 2004)

• “Backward Reasoning”
• Relation between the signs and symptoms and diagnosis
Hypothetico-Deductive Reasoning

• Hypothesis generating and testing involves both inductive and deductive

reasoning
–Induction -to generate the hypothesis
–Deductive -to test hypothesis
Pattern Recognition
• Direct automatic retrieval of information from a well organized
knowledge base
• Non-analytic or forward reasoning
• Experts recognize patterns or “clinical scripts” then perform assessments
to provide further evidence to support their hypothesis. This requires
experience.
Pattern Recognition

• Non-analytic process of reasoning

• “Forward Reasoning”
• Illness Scripts
• Intuition
• Tends to occur unconsciously
Case –part 1

• A 59-year-old African-American man with a history of hypertension,

hyperlipidemia, and cerebrovascular disease presented to the
emergency department complaining of chest pain.
• He stated that the pain began suddenly while he was seated at home
several hours prior to presentation.
• He described the pain as throbbing, 9 out of 10 in intensity,
substernal, and associated with nausea, diaphoresis, and dyspnea.
• He stated that the pain radiated to his left leg but not to his arm or
jaw.
• The pain resolved spontaneously after an hour, but then recurred
3 hours later.
• He had never experienced pain like this before.
• He initially delayed coming to the hospital, expecting the chest pain
to subside spontaneously again; but finally his family brought him in
when he became disoriented and confused.
Thinking, Fast and Slow (Kahneman, 2011)

• Dual process theory: a proposed theory of clinical reasoning in which

the mind uses two distinct yet integrated “systems” when making
decisions
• System 1: based on unconscious reasoning, intuitive, implicit, automatic,
requires little effort, quick
• System 2: conscious reasoning, explicit, controlled, high effort, slow, logical.
Analytic Processes in Clinical Reasoning
Non Analytic Processes in Clinical Reasoning
Combined Processes in Clinical Reasoning
Recognition-Primed Decision Making (Klein’s
Model)
• 1st approach: intuitive or system 1 thinking
• pattern recognition compared against a fully
formed illness script
• Experts have more completely developed illness
scripts than do experienced non-experts
• Experts not only match more points of the
presentation against their illness scripts, but
notice more discrepancies
• Script is a set of interconnected concepts that
allows individuals to make predictions about how
a particular event or sequence of events is likely
to play out.
• Script theory holds that our brains interpret the
world by comparing the attributes of the mental
models it creates with the features of an actual
scene, checking for consistencies and
discrepancies, patterns and irregularities.
• Illness scripts are specialized knowledge
structures that link clinically relevant information
about general disease categories, specific
examples of diseases, and conditions that enable
diseases to flourish in living beings.
• 2nd approach: resembles system 2 thinking
• expert develops a story using his diagnosis,
identifies missing data, and then seeks those data
• If those data are complete and match his initial
thought of diagnosis, he will likely revert to the
first approach and proceed with this diagnosis
• 3rd approach: the use of a mental “premortem”
examination
• expert imagines choosing a given diagnosis with
its resultant treatment
• expert then mentally simulates the potential
consequences
• If the expert still has doubts because the mental
simulation raises cautions, he will seek more
information before committing to the diagnosis
Case –part 2
Initial Evaluation in the ER
• The patient was afebrile with a heart rate of 62 BPM, blood
pressure of 96/47 mmHg, respiratory rate of 18 breaths per
minute, and oxygen saturation of 100 % on ambient air.
• He was well appearing, in no acute distress.
• Heart was regular in rate and rhythm and without murmurs,
rubs, or gallops.
• Lungs were clear to auscultation.
• Abdomen was normal.
• The extremities were warm, with no edema.
• The patient had word-finding difficulty attributed by the
family to a prior stroke, but no other deficits.
• Initial laboratory evaluation:
• sodium 141 mEq/L, potassium 3.5 mEq/L, chloride 106 mEq/L,
bicarbonate 26 mEq/L,
• glucose 121 mg/dL,
• blood urea nitrogen 16 mg/dL, creatinine 1.7 mg/dL,
• creatinine kinase (CK) 82 units/L, CK-MB fraction 1.2 ng/mL, troponin
I 0.154 ng/mL (upper limit of normal is 0.039 ng/dL);
• white blood cell count 12,800 per cubic mm with 85 % neutrophils,
9 % lymphocytes, and 5 % monocytes; hematocrit 44 %,
• prothrombin time 14 s (normal), partial thromboplastin time 35 s;
• urine drug screen was negative for barbiturates, benzodiazepines,
cannabinoids, and cocaine metabolites.
• Dipstick urinalysis only demonstrated 2+ proteinuria.
Case –part 3
Reassessment in the ER
• The patient received 324 mg of aspirin and 1 L of 0.9 % sodium
chloride with subsequent improvement of blood pressure.
• The chest pain resolved, and a repeat neurologic exam was
unchanged.
• A second set of cardiac biomarkers showed a CK-MB of 5.0 ng/mL
and troponin I of 0.643 ng/mL.
• Repeat ECG demonstrated resolution of the T wave inversions.
• The patient received heparin drip and was admitted to a telemetry
monitored bed with the diagnosis of non–ST segment elevation
myocardial infarction (NSTEMI).
Case –part 4

• The patient’s chest pain recurred upon arrival to the medical floor.
The pain was similar but less intense.
• The blood pressure was 172/86 mg Hg.
• Lungs were clear to auscultation.
• He had a crescendo-decrescendo III/VI systolic murmur at the right
upper sternal border and left lower sternal border, and a
decrescendo II/VI diastolic murmur at the left lower sternal border.
No carotid bruits were noted.
• Abdomen was non-tender with no bruits.
• He had a subtle left-sided facial weakness and 4/5 strength on the
left upper and lower extremities. Speech was consistent with
expressive aphasia.
• At this time, troponin I had elevated to 1.726 ng/mL. He received
high-dose atorvastatin, low-dose oral metoprolol, and a nitroglycerin
drip; the heparin drip was continued. He was not given clopidogrel
out of concern that surgery would be required to treat his possibly
acute valvular dysfunction.
Case –part 5

• Three hours later, the patient’s nurse notified the admitting physician
that the patient was having chest pain again.
• The physician noted a difference in blood pressure between arms
(left, 180/60 mmHg; right, 120/40 mmHg).
• An emergent CT angiogram of the chest demonstrated an extensive,
complex Stanford type A aortic dissection extending from the aortic
valve root beyond the renal arteries to the common iliac arteries. It
involved the left coronary artery origin, with decreased flow in the
left coronary system. There was a wedge-shaped infarct in the left
kidney.
• An emergent echocardiogram confirmed severe aortic regurgitation
with a dilated aortic root and a dissection flap.
• The patient underwent emergent surgical repair. He was eventually
discharged to inpatient rehabilitation to recover from the embolic
strokes he had sustained during the dissection.
Stanford type A aortic dissection extending down the length of the thoracic descending aorta.
Involvement of the left main coronary artery and the aortic valve annulus. The dissection
flap in the descending aorta is also seen.
Lesson Learnt

• The ultimate goal: developing diagnostic expertise.

• Develop expertise through the experience of seeing patients and
thinking about their diagnoses systematically.
• Expertise requires knowledge and the development of fully formed
illness scripts.
• Illness scripts can be used to develop a basis for system 1 thinking in simple
scenarios and provide a way of analyzing more complicated presentations so
that an expert can quickly decide when to switch to system 2 thinking.
• Upon switching to system 2 thinking, RPD provides a framework for
mentally simulating a diagnosis and treatment, and for predicting
potential adverse outcomes.
• Diagnoses should be compared with fully formed illness scripts, not
only to determine how closely they match, but also to identify
missing data, which should be promptly gathered.
• Mentally simulating possible effects of therapy is an effective way to
conduct a “pre-mortem analysis” to weigh the consequences of a
decision.
 Step 1: The Patient’s Story
• A 43-year-old woman is brought to the Emergency Room by her
husband at 02.00 in the morning because of acute shortness of
breath.
• Patient states:
• 5 days ago I had a sore throat and sinus congestion.
• I thought it was getting better but then I started coughing and a few times
spit up blood.
• I felt like I had a fever and was feeling cold and hot. Just not feeling my usual
self and unable to do my usual activities.
• I felt sick to my stomach and threw up once.
• Last night my chest felt tight for a few minutes, then this eased up a little.
• I went to sleep but woke up around midnight because I could not catch my
breath. My husband called 911 and the ambulance brought me to the
emergency room.
• 1 week ago my husband had the “flu” and missed work for 3 or 4 days.
Step 2: Data acquisition

• How would you obtain further data from your patient?

What is Data Acquisition

• Pertinent positives and negatives

• Focused physical exam
• Targeted investigations
Step 3: Problem Representation

• How would you summarize this patient?

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
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)
Sample of Problem Representation

• Patient’s age, sex and medical history- 43 year old woman who is a
smoker with bronchitis, generally in good health
• Few days- acute onset
• Sinus congestion, then hemoptysis, then dyspnea- progressive illness
• Sick contact
Step 4:
Generation of Hypotheses
• Differential diagnosis.
Step 5: Illness script

• 43 year old woman

• Predisposing conditions- smoking and bronchitis
• Several days sinus congestion, fever, chills
• Sudden dyspnea and chest tightness, nausea, vomiting
• Occasional hemoptysis
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 (course of illness, illness trajectory, clinical course),
• 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 Ascending Cholecystitis Acute

Cholangitis Hepatitis B

Epidemiology

Temporal Course

Syndrome
Description
Illness Script

Syndrome: Acute Chest Pain

Disease Angina Pulmonary Spontaneous

Embolus Pneumothorax

Epidemiology

Temporal Course

Syndrome
Description
Step 6: Diagnosis