Clinical Reasoning for Classification and Diagnosis

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Introduction

Clinical reasoning involves thinking and decision making in professional practice. This is an important skill for rehabilitation professionals to problem solve and establish a rapport with their patients. It is important to reduce errors and to ensure patient safety. It is described as "a complex, interactive phenomenon, contextualised to the unique situation and workplace of the practitioner, the patient, and the practice model." Two examples of clinical reasoning strategies used in the examination and evaluation of a patient are hypothetico-deductive reasoning and narrative reasoning.

Examination and Evaluation

Comparison of examination and evaluation

Table 1. Comparison of Examination and Evaluation

	Definition	Why is clinical reasoning needed?
Examination	The process of collecting or obtaining data and information about a patient’s condition through various methods such as observation, measurements and specific tests to collect information about the patient’s impairments, activity limitations and participation restrictions.	Clinical reasoning is necessary to select useful questions and measures based on the patient’s problems.
Evaluation	The process of interpreting and integrating the data collected during the examination to make sense of all the information as a whole. It helps the rehabilitation professional draw conclusions about the patient’s condition, identify goals and develop the treatment plan. Evaluation involves making judgements about the significance of the data, identifying patterns and relationships and determining the implications for rehabilitation.	Clinical reasoning is necessary to identify relationships between the patient’s primary problems, impairments, activity limitation and participation.
Examination is about collecting data, while evaluation is about making sense of the data and using it to make informed decisions.

At the end of the evaluation process, the aim in establishing a diagnosis helps guide the development of an appropriate and comprehensive treatment plan.

Clinical Reasoning Strategies for Examination and Evaluation

Two clinical reasoning strategies used in classification and diagnosis are:

1. Hypothetical deductive reasoning
   • Patient cues serve as key elements in creating multiple hypothesis
   • Hypothesis are continuously updated and refined as new information is included
   • " a cognitive, investigative reasoning process"
2. Narrative reasoning
   • Utilises stories to depict clinical encounters, incorporating conditions,  consequences, motivation and interaction 
   • Helps clinicians gain insight into the patient experience and foster empathy skills
   • "a collaborative process between the therapist and the patient"
   • In an educational context, narrative reasoning involves sharing a story, individual reflection and the collaborative exchange of perspectives

In clinical practice, rehabilitation providers use both to organise an examination and evaluate data.

Hypothetico-deductive Reasoning in Rehabilitation

• In medicine, diagnostic characteristics are more apparent – the medical diagnosis is the final step of the hypothetico- deductive model.
  • For example:
    • A patient presenting to the emergency room after waking up with their left arm and leg feeling weak and heavy and they experience a loss of balance. Facial drooping is noticed and the patient is unable to speak. The emergency care provider recognises the stroke-like symptoms (as noted by the American Stroke Association’s warning signs – F.A.S.T. [F = face drooping; A = arm weakness; S = speech difficulty; T = time to call emergency service]) and identifies measures to rule in the hypothesis of a stroke and requests a CT (computed tomography) scan to distinguish between ischemic and haemorrhagic strokes. The medical intervention will be different based on the outcome of the scan.

• In rehabilitation, the final step of diagnosis or categorisation is not always that obvious. There may be diverse categories such as functional deficits, dysphagia or aphasia, and movement deviations.
  • Consider the following example:
    • An interprofessional rehabilitation team discussing a patient with left hemiplegia after stroke. The occupational therapist mentions that the patient is unable to perform activities of daily living involving self-care. She has difficulty dressing and grooming. The speech and language therapist says that the patient experiences difficulty with swallowing and talking. The physiotherapist and orthotist are concerned about the patient having a foot drop on the left side affecting her gait and increasing her risk of falling.
    • The International Classification of Functioning, Disability and Health (ICF) framework can be used to help identify participation restrictions and activity limitations. It is a framework to describe the functioning and disability of an individual in relation to a health condition. In the example above an example of hypothetico-deductive reasoning being used by the occupational therapist may look like this (Table 2):

Table 2. Example of hypothetico-deductive reasoning to identify participation limitations

Rehabilitation professional	Hypothesis	ICF Framework	How to test hypothesis
Occupational therapist	patient has difficulty performing ADLs	Participation restriction - patient is unable to care for herself as expected	Stroke impact scale can be used to confirm hypothesis

Example of Using the ICF model and Hypothetico-deductive Reasoning

Below is another case example to consider.

Case example

A 12-year old female patient with spastic cerebral palsy has difficulty with mobility, fine motor skills and self-care tasks. She also has difficulties with speech and communication. A multidisciplinary rehabilitation team, consisting of a physiotherapist, occupational therapist, prosthetist and speech and language therapist is working collaboratively to address her needs.

Classification of problems according to the ICF Framework

Table 3 provides a a summary of possible problems that the patient may have.

Table 3. Using the ICF Framework to identify patient problems

Body structures and functions	Increased muscle tone in lower limbs Limited range of motion in hip and knee joints Reduced lower limb strength and coordination Limited articulation of words Difficulty in forming coherent sentences Reduced ability to be understood by unfamiliar listeners
Activities	Difficulty walking independently Challenges with fine motor skills (such as writing, buttoning clothes) Impaired speech affects communication
Participation	Difficulty with activities of daily living (ADLs) such as dressing and eating Limited participation in physical activities at school Social interactions affected by speech difficulties
Environmental factors	The patient has a supportive family environment and an accessible home with the necessary modifications. Her school provides an inclusive setting with support services.
Personal factors	The patient is highly motivated and cooperative. She enjoys drawing and participating in creative activities.

If you want you can read more about the ICF:

• Overview of the ICF and Clinical Practice
• International Classification of Functioning, Disability and Health (ICF)
• ICF Checklist

Hypothetico-deductive reasoning process

Table 4 provides possible hypotheses of the different rehabilitation professionals.

Table 4. Possible working hypotheses of different rehabilitation professionals in the given case example

Rehabilitation Professional	Examination	Hypothesis	Goals and Treatment Plan
Physiotherapist	During the examination the physiotherapist observes that the patient is walking with a pronounced limp and requires the use of a walker. Spasticity and limited range of motion in the lower limbs are observed.	Spasticity and muscle weakness in the lower limbs can impair the patient’s ability to walk independently. The limited range of motion in joints can affect the patient’s mobility.  Possible outcome measures that the physiotherapist can use as part of the evaluation to test their hypothesis are the Gross Motor Function Measure (GMFM) to assess the patient’s gross motor function and changes in function over time. The Functional Mobility Scale (FMS) may be used to measure her mobility in different environments. If the patient scores low on the GMFM on the FMS this may indicate limitations in gross motor functions and mobility.	These findings will help with goal setting and the treatment plan. Goals may include improving lower limb strength, reducing spasticity and improving walking ability. Interventions may include strengthening exercises, stretching routines and gait training.
Occupational therapist	During the examination the occupational therapist notes that the patient has difficulties with buttoning her shirt, writing and using utensils when eating.	Spasticity in the upper limbs may affect the patient’s fine motor skills. A lack of adaptive tools may hinder her ability to perform daily tasks independently. Possible tests may include the Pediatric Evaluation of Disability Inventory (PEDI) to evaluate the patient’s capabilities and performance in daily tasks.	Goals may include improving Activities of Daily Living performance of the patient with fine motor skill exercises (e.g. play-based therapy, hand exercises) and recommendation of adaptive tools to help with daily activities (e.g., writing aids, modified utensils)
Prosthetist	During the examination, the patient’s gait is observed and with the assessment of her current orthoses, it is clear that the current orthotic devices are worn out and causing discomfort.	The current orthotic devices may not provide adequate support and may need adjustment. Custom orthoses could improve the patient’s stability and walking ability.	Goals may include better orthotic support for lower limbs and collaboration with the physiotherapist to integrate orthoses into gait training.
Speech and language therapist	The speech therapist observes the patient’s speech during their interactions.	Muscle tone issues may contribute to articulation difficulties. The patient’s limited vocabulary and comprehension are affecting communication. The Goldman-Fristoe Test of Articulation 3(GFTA-3) and the Peabody Picture Vocabulary Test 4th edition (PPVT-4) can be used to evaluate the patient’s speech and language.	Goals may include enhanced speech clarity, improve sentence formation and increase overall communication effectiveness by interventions such as articulation therapy, language development activities and the use of augmentative and alternative communication devices.

HOAC-II and hypothetico-deductive reasoning

Hypothesis-Oriented Algorithm for Clinicians II (HOAC II)

The Hypothesis-Oriented Algorithm for Clinicians II (HOAC-II) is a framework used by rehabilitation professionals to enhance clinical reasoning and decision making. It was developed to guide clinicians through a systematic process of patient examination, evaluation, diagnosis, prognosis and intervention planning. It may help clinicians to identify patient problems, set goals and measure outcomes effectively.

The Algorithm has two parts. Part 1 focuses on the elements of patient management such as examination, evaluation, diagnosis, prognosis and intervention. Part 2 focuses more on intervention and monitoring the effects of intervention and changes to a patient's care plan.

This article provides all the detail on the HOAC-II as well as suggestions on how to use the algorithm:

For the purpose of this page on clinical reasoning for classification and diagnosis, the focus will be on Part 1 of the algorithm. The steps of Part 1 are listed below. Please consult the provided article if you wish to read more. A clinical example will then be used to illustrate the use of the HOAC-II in clinical decision making of a patient with an existing problem.

Steps of HOAC-II Part 1

• Collect initial data
  • information from referring professional
  • medical record of patient
  • observation before formal evaluation
  • patient history
• Generate patient-identified problems (PIPs) list
  • patient describes their problem - functional limitations, etc
  • in patient own words and their views of what they are able to do or not
• Formulate examination strategy
  • based on initial hypotheses constructed from available data and patient identified problems
• Conduct the examination, analyse data, refine hypothesis and perform any additional examination procedures necessary to confirm or discard hypotheses
• Add non-patient-identified problems (NPIPs) to the problem list
  • problems not identified by patient
  • can be identified by clinician or caregivers, family members, etc.
  • these are often anticipated problems
• Generate hypotheses for existing problems as to why the problem exists and/or identify the rationale for believing that anticipated problems are likely to occur unless intervention is provided
• Refine the problem list
• Establish goals for problems
• Establish a testing criteria for every existing problem and/or Establish predictive criteria for anticipated problems
• Establish a plan to reassess the testing and predictive criteria and Establish a plan to assess the status of problems and goals
• Plan intervention strategies based on hypotheses and anticipated problems
• Implement the intervention tactics

Example of Using the HOAC-II and Hypothetico-deductive Reasoning

Here is a case scenario using the HOAC-II alongside hypothetico-deductive reasoning.

Case example: A 45-year-old male with a history of diabetes mellitus, leading to peripheral arterial disease recently underwent a transtibial amputation of the right leg due to severe infection in his left leg. He is motivated to regain his independence and return to work as a software engineer. The multidisciplinary team involved in the patient's care includes a physiotherapist, prosthetist and an occupational therapist.

Table 5. Hypothetico-deductive reasoning and the HOAC-II framework

HOAC-II Framework Steps	Clinical reasoning
Collect initial data	Information from referring professional Referred by surgeon post-amputation Surgeon noted successful healing of the surgical site and recommended rehabilitation Medical record of the patient transtibial amputation due to infection history of diabetes mellitus and peripheral arterial disease current medications include insulin and pain management drugs Observation Patient uses a wheelchair for mobility He appears motivated but shows signs of pain and discomfort in his residual limb Patient has difficulty with transfers from the wheelchair to bed Patient history Patient describes experiencing significant pain in his residual limb and phantom limb sensations He feels weak and finds it challenging to balance while standing on one leg He is concerned about his ability to return to its previous level of function and independence
Patient-identified problems (PIPs)	Patient describes his problem: "I can't walk or stand without assistance." "I feel pain in my stump and sometimes it feels like my leg is still there." "I'm worried I won't be able to do my job or care for myself."
Formulate examination strategy	Initial hypotheses constructed from available data and patient-identified problems Hypothesis 1 Muscle weakness and reduced endurance due to prolonged inactivity Hypothesis 2 Balance issues stemming from the loss of limb and altered centre of gravity Hypothesis 3 Pain management issues related to nerve endings and phantom limb phenomena Planned examinations Assess muscle strength and endurance in remaining limb Evaluate balance through specficic tests (e.g., Berg Balance scale) Measure pain levels and characteristics using pain scales
Conduct the examination, analyse data, refine the hypothesis and additional examinations	Physiotherapist strength testing reveals significant weakness in the right leg and core muscles balance testing shows poor stability on the remaining leg pain assessment shows modern to severe pain levels in the residual limb and phantom limb sensations Prosthetist measurements taken for the residual limb to prepare for prosthetic fitting observes the skin condition of the residual limb, noting slight redness but no open wounds Occupational therapist functional assessment indicates difficulty in performing basic ADLs such as dressing and transferring home environment assessment reveals potential hazards and lack of assistive devices
Non-patient identified problems (NPIP)	Clinicians identify these problems: risk of joint contractures in the residual limb potential for skin breakdown in the residual limb due to prosthesis need for psychological support to cope with the amputation
Hypotheses for existing problems	Muscle weakness and reduced endurance Likely due to prolonged inactivity and loss of lower limb muscle groups Balance issues result from the altered centre of gravity and loss of proprioceptive feedback from the amputated limb Pain management related to nerve endings and phantom limb pain Contracture risk without proper positioning and exercises, there's a high risk of joint contractures Skin breakdown ill-fitting prosthesis can lead to pressure sores and skin irritation Psychological adjustment amputation may lead to anxiety, depression and difficulty adapting to lifestyle changes
Refine the problem list	Muscle weakness and reduced endurance Balance issues Pain and phantom limb sensations Risk of joint contractures Potential skin breakdown Difficulties in performing ADLs Psychological adjustment issues
Establish goals for problems	Muscle strength and endurance improve strength in the remaining limb and core to facilitate mobility Balance enhance stability to prevent falls Pain management reduce pain levels and manage phantom limb sensations Contracture prevention maintain full range of motion in the residual limb Skin integrity prevent skin breakdown by ensuring a proper prosthetic fit ADLs enable independent performance of basic ADLs Psychological adjustment provide support to help the patient adapt his new condition
Establish testing criteria for every existing problem	Muscle strength measure by manual muscle testing scores Balance evaluate through balance tests and fall risk assessments (e.g., Berg Balance Scale) Pain levels assess using pain scales (e.g., Visual Analogue Scale for pain McGill Pain Questionnaire) Joint range of motion monitor through goniometric measurements Skin condition regularly checked for signs of irritation or pressure sores ADLs performance evaluated using functional independence measures (e.g. Functional Independence Measure (FIM), Barthel Index); home and workplace safety (e.g., Safety Assessment of Function and the Environment for Rehabilitation (SAFER) tool Psychological status monitored through patient self-reports and psychological assessments (e.g., Beck Depression Inventory (BDI); Patient Health Questionnaire-9 (PHQ-9)
Plan intervention strategies based on hypotheses	Physiotherapist strengthening exercises for the remaining limb and core balance training using static and dynamic exercises pain management techniques Prosthetist fabricate and fit a custom transtibial prosthesis provide education on prosthesis us and maintenance schedule regular follow-ups for adjustments Occupational therapist training in ADLs with adaptive techniques and devices home and workplace assessments with recommendations for modifications psychological support and coping strategies
Implement intervention tactics	The team implements their respective intervention strategies, continuously communicating and coordinating care to ensure a comprehensive and holistic approach to the patient's rehabilitation.

Narrative Reasoning

Narrative reasoning:

focuses on telling and interpreting stories to guide patient-centered clinical practice

requires the clinician to make inferences about motives of others based on observations

focuses on the person's intentions

the process of understanding patients' experiences with disability within the biopsychosocial context of their lives including beliefs, values and culture

often heard through discussions regarding a clinical encounter

retelling the encounter naturally reveals the interpretation of the patient's intentions, goals and motives

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