University of Baghdad

College of Medicine
2022-2023

Title: Medical Reasoning

Grade:Third
Module: CA
Speaker: Ali Almothaffar
Date: 11-2022
 Learning Objectives
• Upon completion of this presentation, the learner
will be able to independently:
– Identify key features of a patient history and
to synthesize a concise problem
representation
– Construct an accurate patient assessment
– Organize a case presentation using the
PBAR method (Problem Representation,
Background, Analysis, Recommendations)
to trigger the decision-making process.
Stages of learning a skill
How things become a habit
 Definition of Clinical Reasoning
• The term clinical reasoning describes the
process by which health professionals collect
cues, process the information, come to an
understanding of a patient problem or
situation, plan and implement interventions,
evaluate outcomes, and reflect on and learn
from the process(Hoffman, 2007; Kraischsk &
Anthony, 2001; Laurie et al., 2001).
Clinical Reasoning and Critical Thinking
 How often do we need critical
thinking in the clinical setting?
• Bowen J, NEJM,
2006:355;2217-2225
– Pattern recognition
(non-analytical
thinking) is “essential
to diagnostic
expertise”
– “Deliberative analytic
reasoning is primary
strategy when a case
is complex…”
Age and Diagnostic Accuracy

Hobus & Schmidt, 1993

 Cognitive Biases
• Representativeness heuristic - overestimating similarity
between people and events
• Availability heuristic - too much weight to easily available info
• Overconfidence
• Confirmatory bias - bias toward positive and confirming
evidence
• Illusory correlation - perceiving two events as causally related
when there is none
• Putting initial probability as final and not adjusting for
subsequent info

Klein, 2005.
 Factors Affecting Decision Making
They favor appearance of cognitive biases
1-Emotional involvement
2-Trying to impress others
3-Conflict of interest
4 Mental exhaustion: loss of sleep, to much
mental exercise
5 Food deprivation
 Lets Play a Game
• Determine if the conclusion is correct as quick
as possible:
*All roses are flowers
*Some flowers fade quickly
*Therefore some roses fade quickly

What do you think?

 It is Flawed
• Purple=Flowers
• Red =Roses
• Blue = Fade quickly
 How to keep on the right path
• Open mind - willingness to consider
alternative explanations
• Awareness of one’s own cognitive
processes - what type of reasoning was I
using? (metacognition)
• Reflection - how did we go wrong?
Where did we make a mistake?
 Definitions (Noemi Adame, MD)

• Problem Representation—A case presentation that

transforms the patient’s story into a meaningful
clinical problem or a brief summary defining the
case in abstract terms.

• Key Features—Elements of the story such as signs

and symptoms that link to specific categories or
diagnoses and distinguish one diagnoses from
another.

• Abstract Qualifiers (i.e. semantic qualifiers)—Paired,

opposing descriptors or adjectives that can be used
to compare and contrast diagnostic considerations.
 Definitions
• Clinical Reasoning—synonymous with problem-solving,
decision-making, and judgment: The processes clinicians use
to interpret data to make decisions regarding patient
management

• Illness scripts—networks of organized knowledge recalled by

expert clinicians to process information and progress toward
solutions to clinical problems. The PBAR method is organized
to trigger “illness scripts”.

• ROWS (rule-out worse case scenario)—A decision-making

strategy, often used by emergency physicians, to avoid
missing critical diagnoses characterized by a form of pattern
matching of the top 5 or so diagnoses that need to be
excluded for any given clinical presentation5
 PBAR: Problem Representation
(Noemi Adame, MD)
• Key Features
– Trigger “illness scripts”
– Focus on reason for admission/hospitalization
• Abstract Qualifiers
– Examples: flaccid/spastic, high-grade/low-grade,
acute/chronic, firm/soft, recurrent/discrete
– Transform patient-specific details into abstract terms
• “Last night” → acute onset
• “I’ve had this problem before” → recurrent
• “Joint pain in the same knee” → monoarticular
• String the key feature abstractions into one sentence
(occasionally 2-3 sentences)
• This represents the presenting clinical problem.
 PBAR: Background (Noemi Adame, MD)
• Review of Systems
• Past Medical History
• Social History
• Family History
• Physical Exam including Vital Signs
• Laboratory Data before admission
• Radiographic Data before admission
• Course/Work-up done prior to hospitalization
 PBAR: Analysis
• 2-3 most likely diagnoses
• You may generate a longer DDx, but eliminate
the ones that do not fit the patient’s age and
presentation
• Rank the differential diagnosis
• Compare and contrast the diagnoses
• Include ROWS
• Address clinical progress (i.e., improving,
deteriorating, stable etc)
 PBAR: Recommendations
• Diagnostic goals/management
• Therapeutic goals/management
• Identify issues for self-study
–Perform quick literature searches on
diagnoses or problems that are new
• Prioritize issues that can wait until
morning and those that need
immediate attention
• Address discharge goals and discharge
criteria
 The case of A.B.
• A.B. is a 60 year old male teacher who
presented to the emergency department with
chest pain of 1 hour duration.The pain
occurred while the patient was watching TV, it
was sudden and severe and located behind
the sternum and radiating to the back.The
patient became aggitated and developed
shortness of breath and sweating.He had no
cough or sputum or fever.
 The case of A.B.
• A.B. is a 60 year old male teacher who
presented to the emergency department with
chest pain of 1 hour duration.The pain
occurred while the patient was watching TV, it
was sudden and severe and located behind
the sternum and radiating to the back.The
patient became aggitated and developed
shortness of breath and sweating.He had no
cough or sputum or fever.
 The case of A.B.
• Mr A.B. is diabetic for the last 10 years on
metformin and hypertensive for the last 8 years
on atenolol.He works as a teacher in the
secondary school and he does little exercise.
• He developed gall stones 3 years ago and a
cholecystectomy was performed.He is married
with 4 children and his father and uncle died
because of fatal myocardial infarction at the age
of 55 and 58 years respectively.He smokes 20
cigarettes daily for the last 40 years but does not
consume alcohol.
 The case of A.B.
• Mr A.B. is diabetic for the last 10 years on
metformin and hypertensive for the last 8 years
on atenolol. He works as a teacher in the
secondary school and he does little exercise.
• He developed gall stones 3 years ago and a
cholecystectomy was performed.He is married
with 4 children and his father and uncle died
because of fatal myocardial infarction at the age
of 55 and 58 years respectively. He smokes 20
cigarettes daily for the last 40 years but does not
consume alcohol.
 The Case of A.B.Continues
◼ Vital signs: Temp 37c, RR 24, HR 100, BP
150/90 .
◼ GEN: conscious, oriented but agitated.
◼ Head : looks pale with cold sweat , no anemia
no jaundice and normal mouth .
◼ Neck: JVP is slightly elevated
◼ RESP: Clear chest
◼ CV: faint S1 and S2 with S3.
◼ Abdomen: soft, no HSM, no rebound/guarding
◼ Skin: normal.
◼ NEURO :Normal
 The Case of A.B.Continues
◼ Vital signs: Temp 37c, RR 24, HR 100, BP
150/90 .
◼ GEN: conscious, oriented but agitated.
◼ Head : looks pale with cold sweat , no anemia
no jaundice and normal mouth .
◼ Neck: JVP is slightly elevated
◼ RESP: Clear chest
◼ CV: faint S1 and S2 with S3.
◼ Abdomen: soft, no HSM, no rebound/guarding
◼ Skin: normal.
◼ NEURO :Normal
 Reorganizing The Case of A.B.
• Problem Representation
– A.B. is a 60 year old male with acute onset of chest pain and shortness
of breath
• Background
– ROS is positive for sweating .He has a history of diabetes , hypertension
and gall stones.His family history is relevant for coronary events.He is
also a smoker.
• Analysis
– A.B. symptoms are most likely due to an attack of myocardial ischemia
(he has the risk factors) like angina pectoris or myocardial infarction
which is more likely because the pain is prolonged and very severe.
Pleurisy is less likely as the pain behavior is not suggestive but still a
less likely possibility. Musculoskeletal pain is unlikely given the
background pain behavior and associated features.
• Recommendations:
-Admit to hospital
-ask for emergency ECG
-ask for cardiac troponin.
-ask for chest x-ray.
-consider adding analgesia like morphine?
 Conclusions
• Clinical reasoning involves 2 methods , analytic and
heuristic.
• The PBAR method is an effective way to construct
case presentations and to start the process of
decision making regarding patient management .
• A therapeutic plan should be generated , based on
the best evidence,
 References
1.Bowen JL. Educational strategies to promote
clinical diagnostic reasoning. The New
England Journal of Medicine. 2006; 355:2217-
2225.
2.Norman G. Research in clinical reasoning:
past history and current trends. Medical
Education. 2005; 39:418-427.
3.Naomi Adame, Autonomous Decision Making,
National Pediatric Nighttime Curriculum,
University of TX Health Science Center San
Antonio