Chapter 5: Clinical Reasoning, Assessment, and Plan
This chapter guides clinicians through the systematic process of clinical
reasoning, including the development of differential diagnoses, constructing
problem representations, and creating comprehensive assessments and
plans. New medical terms are defined in plain English for better
understanding.
Clinical Reasoning: Process
Dual Processing Theory:
System 1: Intuitive, fast, automatic decision-making based on
heuristics (mental shortcuts). Example: Quickly recognizing classic
signs of a common condition.
System 2: Analytical, slow, controlled reasoning using logic and
evidence. Example: Analyzing complex, atypical cases.
Steps of Clinical Reasoning (Box 5-1):
1. Gather Initial Patient Information:
oHistory (e.g., symptoms, timeline).
oPhysical examination findings.
oPreliminary diagnostic and lab tests.
oPrior health records and clinician input.
2. Organize and Interpret Information:
oCreate a problem representation (summary statement).
oCluster findings into meaningful patterns.
3. Generate Hypotheses:
oDevelop a differential diagnosis (list of possible causes).
oUse illness scripts (mental models of diseases).
4. Test Hypotheses:
oOrder further diagnostic tests.
oReassess findings.
