Introduction to Clinical Reasoning - CHSC 5104

Clinical Encounter

Interaction between clinician and patient.

Patient History

Information about patient’s past and present health.

Chief Complaint

Primary reason patient seeks care.

History of Present Illness (HPI)

Detailed description of current problem.

Past Medical History (PMH)

Prior illnesses, surgeries, medications.

Family History

Health information of relatives.

Social History

Lifestyle, occupation, habits affecting health.

Review of Systems

Systematic check of symptoms across body systems.

Physical Examination

Objective assessment of patient.

Observation

Visual assessment of patient.

Palpation

Feeling tissues for abnormalities.

Percussion

Tapping body structures to assess underlying organs.

Auscultation

Listening to sounds in body (e.g., heart, lungs).

Vital Signs

Blood pressure, heart rate, respiratory rate, temperature.

Symptom

Subjective evidence of disease reported by patient.

Sign

Objective evidence of disease detected by clinician.

Clinical Hypothesis

Tentative explanation for patient’s condition.

Differential Diagnosis

List of possible conditions causing symptoms.

Red Flag

Sign indicating serious or urgent condition.

Clinical Impression

Clinician’s initial evaluation based on encounter.

Patient-Centered Care

Focusing on patient needs and values.

Informed Consent

Patient agreement after understanding options.

Documentation

Recording all clinical findings accurately.

Electronic Health Record (EHR)

Digital patient record system.

Clinical Reasoning

Thought process guiding diagnosis and treatment.

Problem List

Summary of patient issues for management.

Treatment Plan

Strategy to address patient’s conditions.

Follow-Up

Scheduled reassessment of patient progress.

Referral

Sending patient to another healthcare provider.

Interprofessional Collaboration

Working with other health professionals.

Patient Education

Informing patient about condition and care.

Clinical Ethics

Moral principles in patient care.

Confidentiality

Protecting patient information.

Professionalism

Conduct adhering to ethical and clinical standards.

Evidence-Based Practice

Integrating research, clinical expertise, and patient values.

Clinical Decision-Making

Choosing actions based on reasoning and evidence.

Evidence

Information supporting clinical decisions.

Primary Evidence

Original research data.

Secondary Evidence

Summaries or reviews of primary studies.

Tertiary Evidence

Textbooks, guidelines summarizing evidence.

Randomized Controlled Trial (RCT)

Study design randomly assigning participants.

Cohort Study

Observational study following a group over time.

Case-Control Study

Compares patients with a condition to those without.

Cross-Sectional Study

Observes a population at one point in time.

Systematic Review

Comprehensive summary of studies on a topic.

Meta-Analysis

Statistical analysis combining results from multiple studies.

Evidence Hierarchy

Ranking of evidence quality.

Level I Evidence

Highest-quality evidence (e.g., RCT, meta-analysis).

Level II Evidence

Moderate-quality evidence (e.g., cohort studies).

Level III Evidence

Lower-quality evidence (e.g., case reports).

Bias

Systematic error affecting study validity.

Selection Bias

Non-random participant selection.

Performance Bias

Differences in care during study.

Detection Bias

Differences in outcome measurement.

Reporting Bias

Selective reporting of results.

Confounding Variable

Factor influencing both exposure and outcome.

Causation

Cause-and-effect relationship.

Correlation

Association between variables.

Statistical Significance

Likelihood result is not due to chance.

P-Value

Probability result occurred by chance.

Confidence Interval

Range likely containing true effect.

Power

Study’s ability to detect an effect.

Sample Size

Number of participants in study.

Randomization

Assigning participants randomly.

Blinding

Concealing allocation from participants or researchers.

Placebo

Inactive intervention used as control.

Control Group

Group not receiving experimental treatment.

Experimental Group

Group receiving intervention.

Critical Thinking

Objective analysis of information for reasoning.

Assumption

Statement taken as true without proof.

Logical Fallacy

Error in reasoning.

Deductive Reasoning

From general principle to specific conclusion.

Inductive Reasoning

From observations to general conclusion.

Evidence Appraisal

Evaluating quality and relevance of research.

Validity

Accuracy of study results.

Reliability

Consistency of measurement.

Generalizability

Applicability to other populations.

Clinical Relevance

Importance of evidence for patient care.

Bias Detection

Identifying potential distortions in evidence.

Data Interpretation

Making sense of study results.

Causality Assessment

Determining if evidence supports cause-effect.

Search Strategy

Plan for locating evidence.

Database

Organized collection of research articles.

PubMed

Database for biomedical literature.

Cochrane Library

Database of systematic reviews.

Keywords

Words used to search for literature.

Boolean Operators

AND, OR, NOT to refine searches.

MeSH Terms

Standardized medical subject headings.

Citation

Reference to published work.

Abstract

Summary of research article.

Full Text

Complete research article.

Peer Review

Evaluation by other experts before publication.

Study Design

Plan for conducting research.

Randomization

Random assignment of participants.

Blinding

Concealing treatment allocation.

Control

Comparison group in study.

Variable

Measurable factor in study.

Independent Variable

Manipulated factor.

Dependent Variable

Measured outcome.

Confounder

Variable affecting results unintentionally.