View
7
Download
0
Category
Preview:
Citation preview
How to demonstrate good clinical reasoning (tips for your synoptic exam)
Ros Carslake
Director of Veterinary CPD (small animal)
This presentation
• Why is this important?
• What is clinical reasoning?
• Different methods of diagnostic and clinical reasoning
• Demonstrating a logical approach
Why is this important?
• RCVS aims of the synoptic exam:
– Candidates are required to demonstrate competence in application and integration of learning
• RCVS marking scheme
– “Good evidence of critical judgement in selecting, organising and synthesising information to construct sound arguments.”
– “Good powers of analysis and argument”
Why is this important?
• RCVS aims of the synoptic exam:
– Candidates are required to demonstrate competence in application and integration of learning
• RCVS marking scheme
– “Good evidence of critical judgement in selecting, organising and synthesising information to construct sound arguments.”
– “Good powers of analysis and argument”
?
Why is this important?
• What do you know?
• How does that relate to this patient?
• What are you going to do next?
• Why are you going to do this?
Why is this important?
• What do you know?
• How does that relate to this patient?
• What are you going to do next?
• Why are you going to do this?
“Critical judgement”
“Analysis and argument”
Why is this important?
• Feedback from examiners:
Why is this important?
• Feedback from examiners:
• Failure to demonstrate and verbalise a sound and logical clinical reasoning
Why is this important?
• Feedback from examiners:
• Failure to demonstrate and verbalise a sound and logical clinical reasoning
• Pattern recognition
Why is this important?
• Feedback from examiners:
• Failure to demonstrate and verbalise a sound and logical clinical reasoning
• Pattern recognition
• Incomplete or poorly prioritised problem lists
Why is this important?
• Feedback from examiners:
• Failure to demonstrate and verbalise a sound and logical clinical reasoning
• Pattern recognition
• Incomplete or poorly prioritised problem lists
• Inability to give major differentials for common problems/ differentials not being ordered or logical
Clinical reasoning
• Undertaken by all clinicians
• Often automatic
• Cognitive process that underlies diagnosis/management of a patient’s presenting problem
Clinical reasoning
• Undertaken by all clinicians
• Often automatic
• Cognitive process that underlies diagnosis/management of a patient’s presenting problem
• “an ability to integrate and apply different types of knowledge, to weight evidence, critically think about arguments and to reflect on the process to arrive at a
diagnosis”
To make a diagnosis…
To make a diagnosis…
Collection of information
(Chief complaint, disease
history, examination)
To make a diagnosis…
Collection of information
(Chief complaint, disease
history, examination)
Diagnostic
possibilities
(problem lists,
differential
diagnoses)
To make a diagnosis…
Collection of information
(Chief complaint, disease
history, examination)
Diagnostic
possibilities
(problem lists,
differential
diagnoses)
Select diagnostic
tests/procedures
(interpret the
results)
To make a diagnosis…
Collection of information
(Chief complaint, disease
history, examination)
Diagnostic
possibilities
(problem lists,
differential
diagnoses)
Select diagnostic
tests/procedures
(interpret the
results)
Diagnosis!
To make a diagnosis…
Collection of information
(Chief complaint, disease
history, examination)
Diagnostic
possibilities
(problem lists,
differential
diagnoses)
Select diagnostic
tests/procedures
(interpret the
results)
Management
planDiagnosis!
To make a diagnosis…
Collection of information
(Chief complaint, disease
history, examination)
Diagnostic
possibilities
(problem lists,
differential
diagnoses)
Select diagnostic
tests/procedures
(interpret the
results)
Management
planDiagnosis!
To make a diagnosis…
Collection of information
(Chief complaint, disease
history, examination)
Diagnostic
possibilities
(problem lists,
differential
diagnoses)
Select diagnostic
tests/procedures
(interpret the
results)
Management
planDiagnosis!
Knowledge
To make a diagnosis…
Collection of information
(Chief complaint, disease
history, examination)
Diagnostic
possibilities
(problem lists,
differential
diagnoses)
Select diagnostic
tests/procedures
(interpret the
results)
Management
planDiagnosis!
Knowledge
Understanding
Diagnostic methods
• Varying degrees of complexity required
• Experience counts
• At least 6 approaches to making a diagnosis, of varying complexity
Diagnostic approaches
• Pattern recognition
• Hypothetico-deductive reasoning
• Exhaustive method
• Problem-oriented method
Pattern recognition
• Very commonly used
• Diagnosis made quickly and reflexly
• Quick and accurate when used by an experienced clinician
• Obvious disadvantages
– Limited diagnostic possibilities
– Over-reliance can perpetuate inaccurate diagnoses
– Regional differences
Pattern recognition
• A 16-wk-old kitten, recently acquired from a cat shelter, with focal alopecia around the face.
Pattern recognition
• A 16-wk-old kitten, recently acquired from a cat shelter, with focal alopecia around the face.
Ringworm
Pattern recognition
• A 16-wk-old kitten, recently acquired from a cat shelter, with focal alopecia around the face.
Ringworm
•A 14yo overweight pony with sudden onset forelimb lameness/reluctance to move
Pattern recognition
• A 16-wk-old kitten, recently acquired from a cat shelter, with focal alopecia around the face.
Ringworm
•A 14yo overweight pony with sudden onset forelimb lameness/reluctance to move
Laminitis
Hypothetico-deductive method
• Commonly used diagnostic reasoning
• Key or pivotal clinical sign or problem
• Short-list of diagnostic possibilities/hypotheses
• Test the hypotheses
– Focussed questioning, clinical exam,
• Ordered differential diagnoses list
• Select diagnostic tests accordingly
Hypothetico-deductive method
• 8yo horse presenting with a 2 day history of severe diarrhoea, signs of dehydration, lethargy, grade 1/6 systolic heart murmur
Hypothetico-deductive method
• 8yo horse presenting with a 2 day history of severe diarrhoea, signs of dehydration, lethargy, grade 1/6 systolic heart murmur
Hypothetico-deductive method
• 8yo horse presenting with a 2 day history of severe diarrhoea, signs of dehydration, lethargy, grade 1/6 systolic heart murmur
diarrhoea
Hypothetico-deductive method
• 8yo horse presenting with a 2 day history of severe diarrhoea, signs of dehydration, lethargy, grade 1/6 systolic heart murmur
• 10yo GSD presenting with a progressive RH lameness, recent decrease in appetite and perceived weight loss
diarrhoea
Hypothetico-deductive method
• 8yo horse presenting with a 2 day history of severe diarrhoea, signs of dehydration, lethargy, grade 1/6 systolic heart murmur
• 10yo GSD presenting with a progressive RH lameness, recent decrease in appetite and perceived weight loss
diarrhoea
Hypothetico-deductive method
• 8yo horse presenting with a 2 day history of severe diarrhoea, signs of dehydration, lethargy, grade 1/6 systolic heart murmur
• 10yo GSD presenting with a progressive RH lameness, recent decrease in appetite and perceived weight loss
diarrhoea
lameness
Exhaustive method
• Exhaustive history and exam
• Extensive baseline/screening testing, as far as finances allow
• Sift through data for clues
• Rare diseases/ other approaches failed
• Spurious and redundant clues
Problem-oriented approach
• Relate to both exhaustive and hyopthetico-deductive methods.
• Complete history and exam
• Key problems/signs identified and weighted
• Individual differential diagnoses lists formed
• Diagnostic testing aims to rule in/out diseases
• Repeated testing frames a diagnosis
• Ideal for complex/multiple diseases
Logical case approach
• Pattern recognition
• Hypothetico-deductive reasoning
• Exhaustive method
• Problem-oriented method
In an exam situation:
Logical case approach
• Pattern recognition
• Hypothetico-deductive reasoning
• Exhaustive method
• Problem-oriented method
• Pattern recognition
• Hypothetico-deductive reasoning
• Exhaustive method
• Problem-oriented method
In an exam situation:
So remember….
• Create a prioritised and complete problem list
• Devise a logical and prioritised DDx list
• Critically select and rationalise any tests chosen.
• Explain/reason case management decisions keeping in mind the individual case
So remember….
• Create a prioritised and complete problem list
• Devise a logical and prioritised DDx list
• Critically select and rationalise any tests chosen.
• Explain/reason case management decisions keeping in mind the individual case
Case examples:
• 14yo cat with 1 month history of weight loss and intermittent vomiting. Appetite slightly reduced.
• Exam: BCS 3/9, HR 190, normal rhythm, mild dehydration, abdominal palpation normal.
Case examples:
• 14yo cat with 1 month history of weight loss and intermittent vomiting. Appetite slightly reduced.
• Exam: BCS 3/9, HR 190, normal rhythm, mild dehydration, abdominal palpation normal.
Case examples:
• Weight loss/underweight
• Vomiting
• Tachycardia
• Mild dehydration
• (mildly decreased appetite)
Case examples:
• Weight loss/underweight
• Vomiting
• Tachycardia
• Mild dehydration
• (mildly decreased appetite)
So remember….
• Create a prioritised and complete problem list
• Devise a logical and prioritised DDx list
• Critically select and rationalise any tests chosen.
• Explain/reason case management decisions keeping in mind the individual case
So remember….
• Create a prioritised and complete problem list
• Devise a logical and prioritised DDx list
• Critically select and rationalise any tests chosen.
• Explain/reason case management decisions keeping in mind the individual case
So remember….
• Create a prioritised and complete problem list
• Devise a logical and prioritised DDx list
• Critically select and rationalise any tests chosen.
• Explain/reason case management decisions keeping in mind the individual case
Good Luck!
Recommended