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Developing ClinicalProblem-Solving Skills
HirlanSub Bag Gartroenterologi HepatologiSub Bag Gartroenterologi Hepatologi
Bagian Ilmu Penyakit DalamBagian Ilmu Penyakit DalamRS Dr Kariai !K "nipRS Dr Kariai !K "nip
SemarangSemarang
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Patient#s In$ormation
Problem synt%esis&ultiple%ypot%esis
In'uirystrategy
Basic structure o$ clinical reasoning processBasic structure o$ clinical reasoning process
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Stages o$ t%e p%ysician#s clinical reasoning proc
() Hypot%esis generation
*) In'uiry strategy+) Data analysis
,) Problem synt%esis
) Diagnostic an treatment ecision-making
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De.nition o$ term
Hypot%esis /H
ypot%esis /a proposition 0 set o$ propositions
as an e1planation $or t%e occurrence o$ some speci.e group o$ p%enomena eit%er asserte merely as a pro$essional con2ecture to guie investigation or
accepte as t%e %ig%ly probable in t%e lig%t o$ establis%e $acts
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Hypot%esis
3abel 45%atever6 t%at best e1plain t%epossible causes $or t%e patients problem)
7isease processes7pat%ological processes7clinical entities 0 synrome7p%ysiological erangements
7etiological process7a8ecte organ0tissue7psyc%ological processes7social or economical $actors
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DiagnosisDiagnosis
3abel o$ isease /
- Speci.c organ
- Process - 9t%iology
!inal iagnosis
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IntuitionIntuition
Clinician#s ecision about correct 1 or t1 5%e
insu:cient ob2ective evienceor clear-cut reasons are not available
C%aracteristic o$ t%ee1perience clinician
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&etacognition&etacognition
Involves eliberation;re
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!orming t%e initial concept!orming t%e initial concept
Patient#s in$ormation
Perception
>nalysis
Initial conceptInitial concept
Details are important look at everything that could be signifcant
Be careul, the hazard obias
Keeping the initial concept exible
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Developing t%e initialconcept
=racking patient ata /73ook at t%e patient care$ully
73istening care$ully
7=ry to be as ob2ective as you can
Pull t%e in$ormation toget%er initialconcept
%ypot%esis5ill $ollo5
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Generating multiple
%ypot%esisHypot%esis are generate early in t%e patient encounter
?$ten keep t%e initial %ypot%esis very broa $rames t%e %ypot%esis in anatomical 0 pat%op%ysiological term
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Patient#s in$ormation
Perception
>nalysis
Initial concept &ultiple %ypot%In'uiry strategy
Generating multiple %ypot%esisGenerating multiple %ypot%esis
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Designing in'uiry strategy
Components o$ in'uiry strategy
- euction - insu.ciency - scan
- searc%
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Scanning
7 non-%ypot%esis oriente
systemic intervie5 an p%ysical e1amination7 complements t%e $ocuse searc% o$ euctive in'u7 time consume 0 lu1ury
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Searc%
7 Deuctive in'uiry; esigne to resolve en7 Problem oriente activity;
'uestions an e1amination are carrie ou
ata guie by %ypot%esis
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=%e %istory
!unamental $our / present illness past %istory $amily %istory psyc%osocial %is
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Present illness
Sacre seven / location 'uality
'uantity0 severity timing 4onset; uration
setting $actors t%at %ave aggr
>ssociate mani$estati
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Present illness
7 ?nset o$ symptom7 events surrouning t%e onset7 'uality an intensity o$ t%e symptom
7 associate symptom7 =emporal symptom7 Se'uence o$ symptom7 locali@ation
7 relieving an aggravating $actors
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>pproac% to t%e present illness
7greeting t%e patient7t%e patient#s com$ort7opening 'uestions7$ollo5ing t%e patient#s leas /
$acilitation re
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Revie5 o$ systems
Scanning met%oe?nly i$ neee; as complements
o$ problem oriente intervie5
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P%ysical e1amination
&ost o$ iagnosis process 5ere base on %istory91perience p%ysician usually nee only a $e5 particular
e1amination to con.rm %is iagnostic ecision
- learn care$ully %o5 to searc% t%e abnormality - al5ays consistent 5it% p%ysical e1amination tec%ni - poor tec%ni'ue can prouce $alse .ning
- al5ays learn to kno5 5%at 5e %ave to looking $or=%e rest o$ p%ysical e1amination is scanning met%o
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Patients in$ormation
Perception
>nalysis
Synt%esis 5it%
Initial concept
&ultiple
%ypot%esis
Auestions e1amination
clinical skill
in'uiry strategy
searc% an scan
Clinical skill are tool of inquiry strategy
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Patient in$ormation
Perception
>nalysis
Problem synt%esis
Diagnosis ecision
=%erapeutic ecision
=est clinical skill
In'uiry strategy
be%aviormoi.cation
Rational be%avior
Compliance
multiple %ypot%esis
Patienteucation=%e .nal step