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Chapter 003. Decision-Making in Clinical Medicine (Part 2)

The following three examples introduce the subject of clinical reasoning: A 46-year-old man presents to his internist with a chief complaint of hemoptysis. The physician knows that the differential diagnosis of hemoptysis includes over 100 different conditions, including cancer and tuberculosis. The examination begins with some general background questions, and the patient is asked to describe his symptoms and their chronology. By the time the examination is completed, and even before any tests are run, the physician has formulated a working diagnostic hypothesis and planned a series of steps to test it. In an otherwise healthy and nonsmoking patient recovering from. | Chapter 003. Decision-Making in Clinical Medicine Part 2 The following three examples introduce the subject of clinical reasoning A 46-year-old man presents to his internist with a chief complaint of hemoptysis. The physician knows that the differential diagnosis of hemoptysis includes over 100 different conditions including cancer and tuberculosis. The examination begins with some general background questions and the patient is asked to describe his symptoms and their chronology. By the time the examination is completed and even before any tests are run the physician has formulated a working diagnostic hypothesis and planned a series of steps to test it. In an otherwise healthy and nonsmoking patient recovering from a viral bronchitis the doctor s hypothesis would be that the acute bronchitis is responsible for the small amount of blood-streaked sputum the patient observed. In this case a chest x-ray may provide sufficient reassurance that a more serious disorder is not present. A second 46-year-old patient with the same chief complaint who has a 100-pack-year smoking history a productive morning cough and episodes of blood-streaked sputum may generate the principal diagnostic hypothesis of carcinoma of the lung. Consequently along with the chest x-ray the physician obtains a sputum cytology examination and refers this patient for fiberoptic bronchoscopy. A third 46-year-old patient with hemoptysis who is from a developing country is evaluated with an echocardiogram as well because the physician thinks she hears a soft diastolic rumbling murmur at the apex on cardiac auscultation suggesting rheumatic mitral stenosis. These three simple vignettes illustrate two aspects of expert clinical reasoning 1 the use of cognitive shortcuts as a way to organize the complex unstructured material that is collected in the clinical evaluation and 2 the use of diagnostic hypotheses to consolidate the information and indicate appropriate management steps. The Use of Cognitive .