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Clinical Reasoning, Assessment, and Plan: A Guide for Healthcare Professionals, Study notes of Nursing

This chapter provides a detailed guide to clinical reasoning, assessment, and plan development for healthcare professionals. It covers the dual processing theory, steps of clinical reasoning, illness scripts, semantic qualifiers, problem representation, hypothesis generation, common diagnostic errors, strategies to avoid errors, and documentation practices. The chapter emphasizes the importance of systematic thinking, evidence-based decision-making, and patient-centered care.

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2024/2025

Uploaded on 01/13/2025

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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.
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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: o History (e.g., symptoms, timeline). o Physical examination findings. o Preliminary diagnostic and lab tests. o Prior health records and clinician input.
  2. Organize and Interpret Information: o Create a problem representation (summary statement). o Cluster findings into meaningful patterns.
  3. Generate Hypotheses: o Develop a differential diagnosis (list of possible causes). o Use illness scripts (mental models of diseases).
  4. Test Hypotheses: o Order further diagnostic tests. o Reassess findings.
  1. Select a Working Diagnosis: o Choose the most plausible explanation for the problem.
  2. Plan the Diagnostic and Treatment Strategy: o Develop a patient-centered plan. Illness Scripts:  Mental representations of diseases, including typical presentations, key features, and differentiating factors. Semantic Qualifiers:  Comparative descriptors like "acute vs. chronic" or "localized vs. diffuse" that refine differential diagnoses. Synthesizing Clinical Information Problem Representation:  A concise summary of the patient’s key information (symptoms, findings, risk factors) that drives hypothesis generation. Example (Box 5-2):Initial: A 57-year-old male with acute chest pain.  Expanded: A 57-year-old male with congestive heart failure and a 35- pack-year smoking history presenting with exertional retrosternal pain. Hypothesis Generation (Box 5-3):  For each cluster of findings, consider: o Anatomic location. o Pathophysiology. o Risk factors. Diagnostic Hypotheses Example:Anatomic Approach: Focus on the involved body part.  Pathophysiologic Approach: Analyze dysfunctions (e.g., ischemia, infection).

o Prioritize differential diagnoses.

  1. Plan: o Specify diagnostic tests, treatments, patient education, referrals, and follow-up. o Incorporate shared decision-making and patient preferences. Example Summary Statement: "A 45-year-old female with a history of hypertension presenting with acute, unilateral, throbbing headache and associated photophobia and nausea." Recording Your Findings SOAP Note Format:
  2. Subjective: Patient’s symptoms and history.
  3. Objective: Physical exam findings and test results.
  4. Assessment: Synthesized problem representation.
  5. Plan: Comprehensive care strategy. Example SOAP Note (Box 5-10):Subjective: "I’ve had a fever and cough for 3 days."  Objective: T 38.5°C, crackles in the left lung base.  Assessment: Likely bacterial pneumonia.  Plan: Prescribe antibiotics, chest X-ray, follow-up in 1 week. Patient Problem List (Box 5-11):  Active and resolved problems with onset dates.  Example: o 1/2024: Hypertension. o 3/2024: Acute bronchitis (resolved). Key Medical Terms with Plain English Descriptions:

Heuristics: Mental shortcuts used for quick decision-making.  Illness Script: A detailed mental model of a specific disease.  Semantic Qualifiers: Descriptors used to compare and differentiate diagnoses.  Anchoring Bias: Sticking to an initial impression despite new evidence.  Framing Effect: Decision influenced by how information is presented. This detailed guide ensures no critical information is omitted, integrating all medical terms, key processes, and illustrative examples for optimal learning.