Clinical Reasoning for Classification and Diagnosis: Difference between revisions
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# Hypothetical deductive reasoning<ref name=":2" /> <ref>Yazdani S, Hosseinzadeh M, Hosseini F. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5611427/pdf/JAMP-5-177.pdf Models of clinical reasoning with a focus on general practice: a critical review.] Journal of advances in medical education & professionalism. 2017 Oct;5(4):177.</ref> | # Hypothetical deductive reasoning<ref name=":2" /> <ref>Yazdani S, Hosseinzadeh M, Hosseini F. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5611427/pdf/JAMP-5-177.pdf Models of clinical reasoning with a focus on general practice: a critical review.] Journal of advances in medical education & professionalism. 2017 Oct;5(4):177.</ref> | ||
#* Patient cues serve as key elements in creating multiple hypothesis | #* Patient cues serve as key elements in creating multiple hypothesis | ||
#* Hypothesis are continuously updated and refined as new information is included<ref>Schaaf RC. Creating evidence for practice using data-driven decision-making. The American Journal of Occupational Therapy. 2015 Mar 1;69(2):6902360010p1-6.</ref><ref>Rothstein JM, Echternach JL, Riddle DL. The Hypothesis-Oriented Algorithm for Clinicians II (HOAC II): a guide for patient management. Physical Therapy. 2003 May 1;83(5):455-70.</ref> | #* Hypothesis are continuously updated and refined as new information is included<ref>Schaaf RC. Creating evidence for practice using data-driven decision-making. The American Journal of Occupational Therapy. 2015 Mar 1;69(2):6902360010p1-6.</ref><ref name=":6">Rothstein JM, Echternach JL, Riddle DL. The Hypothesis-Oriented Algorithm for Clinicians II (HOAC II): a guide for patient management. Physical Therapy. 2003 May 1;83(5):455-70.</ref> | ||
#* " A cognitive, investigative reasoning process"<ref name=":2" /> | #* " A cognitive, investigative reasoning process"<ref name=":2" /> | ||
# Narrative reasoning<ref name=":2" /> <ref name=":4">Haines D, Wright J. Thinking in stories: Narrative reasoning of an occupational therapist supporting people with profound intellectual disabilities’ engagement in occupation. Occupational Therapy In Health Care. 2023 Jan 3;37(1):177-96.</ref><ref name=":0">Mattingly C. The narrative nature of clinical reasoning. The American Journal of Occupational Therapy. 1991 Nov 1;45(11):998-1005.</ref><ref name=":3">Mattingly C. In search of the good: Narrative reasoning in clinical practice. Medical anthropology quarterly. 1998 Sep;12(3):273-97.</ref><ref name=":1">Milota MM, van Thiel GJ, van Delden JJ. Narrative medicine as a medical education tool: a systematic review. Medical teacher. 2019 Jul 3;41(7):802-10.</ref> | # Narrative reasoning<ref name=":2" /> <ref name=":4">Haines D, Wright J. Thinking in stories: Narrative reasoning of an occupational therapist supporting people with profound intellectual disabilities’ engagement in occupation. Occupational Therapy In Health Care. 2023 Jan 3;37(1):177-96.</ref><ref name=":0">Mattingly C. The narrative nature of clinical reasoning. The American Journal of Occupational Therapy. 1991 Nov 1;45(11):998-1005.</ref><ref name=":3">Mattingly C. In search of the good: Narrative reasoning in clinical practice. Medical anthropology quarterly. 1998 Sep;12(3):273-97.</ref><ref name=":1">Milota MM, van Thiel GJ, van Delden JJ. Narrative medicine as a medical education tool: a systematic review. Medical teacher. 2019 Jul 3;41(7):802-10.</ref> | ||
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==== Hypothesis-Oriented Algorithm for Clinicians II (HOAC II) ==== | ==== 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 Hypothesis-Oriented Algorithm for Clinicians II (HOAC-II)<ref>Rothstein JM, Echternach JL, Riddle DL. [https://watermark.silverchair.com/ptj0455.pdf?token=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3ZL_9Cf3qfKAc485ysgAAA3IwggNuBgkqhkiG9w0BBwagggNfMIIDWwIBADCCA1QGCSqGSIb3DQEHATAeBglghkgBZQMEAS4wEQQMmKayyJIK2SrmstTiAgEQgIIDJXUaoFrcMUtZAgWVBacBLmwc0N5n-jUh2OxVZeFNp244hWbWzI9eDunIT067GlRIU1zZqwaywunQfAb2-IuUZo_HwoJrcCZlQGBwFxVPwMldoae8XwSx07pquLzCUK79wVGp8gyU0WI50VLfMbvcXq_nmbNcD84jo_wmIBcX8azklVqGWINKpIhRx018zBVRzh8bKCKn_i70ObIEd4jErRjpqmJbScSpNd-1mpNSICYy47RHDlzBhPP_L57nnkN8c4McxXss109ZuhKnjGAaNtflZmr5DbcbwDzy8k_uG3_ehBKN4u1N6jT1F9I-P25zOiJGmN7tAe3nq8plCxbHxDH2nELlUDvzTcP_St8MOgTnHZ_mDPjWCVVemLeCvE9trXv7puaExuxX3iZOBTsL6TeDzNZkoz4Q8ie45hrRcAcH5-L2nwyMUhKhmoHe9VtOcz-Ex4aQTUcVXWprLEsOZPa7ZmLIX8ujAZMoqdXg-jnYZi8gcj1Yw7imEze5bp1tMwMrELCYOCwgFnFJSl45QqsSdlvkGqoUHzF-BTfF6ckgOl_mqIvZb1h9PztzzfK_9oy9IthLYF6eNRGsvVNa244OG-_hN3s_HDMjRQgMTtFO1A51aKhbnTy3n9HZ5JjmkFlnXxHo3EmJJSr-8GTNGg3XQ700jmoVx6_s5zkBgWrGj2yPz5e29Ll0UKBhCd0Pi5vtSNxv1lRoq8iGAoTpMKJmqOP48l9dZjxV3IiedBLCdA4RBcGTCZu1o7EusTFBlJfGlIY1yirUpmfj5ST_ejuD9UnhsACyHRc_r4eYPUgxA2Iz1Jw3Z8apF1ev6BLlYIEZEXzBWgBRAfNuqhd2uXFZffj7-lXJ2-eYfj05rvzFZuwGGRtkBX9KGbHjf1XKE26zIfuqOVLI84FF2F4LMJVV5GWjRpZss52FpyOFF7112o5mxnkimWVPhGElmsJJg_yoSuOVTrMyecy32_MhnX3Ku4nRUoJxUzhCNEeV52V_mxoZQ19wzlanuJwKBB6swjQdQO1ZXUjW3wuJ0pCL8s1cyZHzj4rSEzMGPowGbXa3JEV0UOM The Hypothesis-Oriented Algorithm for Clinicians II (HOAC II): a guide for patient management.] Physical Therapy. 2003 May 1;83(5):455-70.</ref> 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 | 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: | This article provides all the detail on the HOAC-II as well as suggestions on how to use the algorithm: [https://watermark.silverchair.com/ptj0455.pdf?token=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3ZL_9Cf3qfKAc485ysgAAA3IwggNuBgkqhkiG9w0BBwagggNfMIIDWwIBADCCA1QGCSqGSIb3DQEHATAeBglghkgBZQMEAS4wEQQMmKayyJIK2SrmstTiAgEQgIIDJXUaoFrcMUtZAgWVBacBLmwc0N5n-jUh2OxVZeFNp244hWbWzI9eDunIT067GlRIU1zZqwaywunQfAb2-IuUZo_HwoJrcCZlQGBwFxVPwMldoae8XwSx07pquLzCUK79wVGp8gyU0WI50VLfMbvcXq_nmbNcD84jo_wmIBcX8azklVqGWINKpIhRx018zBVRzh8bKCKn_i70ObIEd4jErRjpqmJbScSpNd-1mpNSICYy47RHDlzBhPP_L57nnkN8c4McxXss109ZuhKnjGAaNtflZmr5DbcbwDzy8k_uG3_ehBKN4u1N6jT1F9I-P25zOiJGmN7tAe3nq8plCxbHxDH2nELlUDvzTcP_St8MOgTnHZ_mDPjWCVVemLeCvE9trXv7puaExuxX3iZOBTsL6TeDzNZkoz4Q8ie45hrRcAcH5-L2nwyMUhKhmoHe9VtOcz-Ex4aQTUcVXWprLEsOZPa7ZmLIX8ujAZMoqdXg-jnYZi8gcj1Yw7imEze5bp1tMwMrELCYOCwgFnFJSl45QqsSdlvkGqoUHzF-BTfF6ckgOl_mqIvZb1h9PztzzfK_9oy9IthLYF6eNRGsvVNa244OG-_hN3s_HDMjRQgMTtFO1A51aKhbnTy3n9HZ5JjmkFlnXxHo3EmJJSr-8GTNGg3XQ700jmoVx6_s5zkBgWrGj2yPz5e29Ll0UKBhCd0Pi5vtSNxv1lRoq8iGAoTpMKJmqOP48l9dZjxV3IiedBLCdA4RBcGTCZu1o7EusTFBlJfGlIY1yirUpmfj5ST_ejuD9UnhsACyHRc_r4eYPUgxA2Iz1Jw3Z8apF1ev6BLlYIEZEXzBWgBRAfNuqhd2uXFZffj7-lXJ2-eYfj05rvzFZuwGGRtkBX9KGbHjf1XKE26zIfuqOVLI84FF2F4LMJVV5GWjRpZss52FpyOFF7112o5mxnkimWVPhGElmsJJg_yoSuOVTrMyecy32_MhnX3Ku4nRUoJxUzhCNEeV52V_mxoZQ19wzlanuJwKBB6swjQdQO1ZXUjW3wuJ0pCL8s1cyZHzj4rSEzMGPowGbXa3JEV0UOM The Hypothesis-Oriented Algorithm for Clinicians II (HOAC II): a guide for patient management.]<ref name=":6" /> | ||
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. | 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 ===== | ===== Steps of HOAC-II Part 1 ===== | ||
* Collect initial data | * Collect initial data<ref name=":6" /> | ||
** information from referring professional | ** information from referring professional | ||
** medical record of patient | ** medical record of patient | ||
** observation before formal evaluation | ** observation before formal evaluation | ||
** patient history | ** patient history | ||
* Generate patient-identified problems (PIPs) list | * Generate patient-identified problems (PIPs) list<ref name=":6" /> | ||
** patient describes their problem - functional limitations, etc | ** patient describes their problem - functional limitations, etc | ||
** in patient own words and their views of what they are able to do or not | ** in patient own words and their views of what they are able to do or not | ||
* Formulate examination strategy | * Formulate examination strategy<ref name=":6" /> | ||
** based on initial hypotheses constructed from available data and patient identified problems | ** 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 | * Conduct the examination, analyse data, refine hypothesis and perform any additional examination procedures necessary to confirm or discard hypotheses<ref name=":6" /> | ||
* Add non-patient-identified problems (NPIPs) to the problem list | * Add non-patient-identified problems (NPIPs) to the problem list<ref name=":6" /> | ||
** problems not identified by patient | ** problems not identified by patient | ||
** can be identified by clinician or caregivers, family members, etc. | ** can be identified by clinician or caregivers, family members, etc. | ||
** these are often anticipated problems | ** 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 | * 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<ref name=":6" /> | ||
* Refine the problem list | * Refine the problem list<ref name=":6" /> | ||
* Establish goals for problems | * Establish goals for problems<ref name=":6" /> | ||
* Establish a testing criteria for every existing problem and/or | * Establish a testing criteria for every existing problem and / or establish predictive criteria for anticipated problems<ref name=":6" /> | ||
* Establish a plan to reassess the testing and predictive criteria and | * Establish a plan to reassess the testing and predictive criteria and establish a plan to assess the status of problems and goals<ref name=":6" /> | ||
* Plan intervention strategies based on hypotheses and anticipated problems | * Plan intervention strategies based on hypotheses and anticipated problems<ref name=":6" /> | ||
* Implement the intervention tactics | * Implement the intervention tactics<ref name=":6" /> | ||
==== Example of Using the HOAC-II and Hypothetico-deductive Reasoning ==== | ==== Example of Using the HOAC-II and Hypothetico-deductive Reasoning ==== | ||
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'''Case example''' | '''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. | ''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.'' | ||
{| class="wikitable" | {| class="wikitable" | ||
|+Table 5. Hypothetico-deductive reasoning and the HOAC-II framework | |+Table 5. Hypothetico-deductive reasoning and the HOAC-II framework | ||
!HOAC-II Framework Steps | !HOAC-II Framework Steps<ref name=":6" /> | ||
!Clinical reasoning | !Clinical reasoning | ||
|- | |- |
Revision as of 16:13, 17 June 2024
Original Editor - User Name
Top Contributors - Wanda van Niekerk and Jess Bell
Introduction[edit | edit source]
Clinical reasoning involves thinking and decision making in professional practice.[1] [2] 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."[1] Two examples of clinical reasoning strategies used in the examination and evaluation of a patient are hypothetico-deductive reasoning[3] and narrative reasoning.
Examination and Evaluation[edit | edit source]
Table 1 shows a comparison of examination and evaluation and why clinical reasoning is necessary for these.
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.[4]
Clinical Reasoning Strategies for Examination and Evaluation[edit | edit source]
Two clinical reasoning strategies used in classification and diagnosis are:
- Hypothetical deductive reasoning[1] [5]
- Narrative reasoning[1] [8][9][10][11]
- Utilises stories to depict clinical encounters, incorporating conditions, consequences, motivation and interaction[9]
- Helps clinicians gain insight into the patient experience and foster empathy skills[12]
- "A collaborative process between the therapist and the patient"[1]
- In an educational context, narrative reasoning involves sharing a story, individual reflection and the collaborative exchange of perspectives[11]
In clinical practice, rehabilitation providers use both to organise an examination and evaluate data.[4]
Hypothetico-deductive Reasoning in Rehabilitation[edit | edit source]
- In medicine, diagnostic characteristics are more apparent – the medical diagnosis is the final step of the hypothetico- deductive model.
- For example[4]:
- 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.
- For example[4]:
- In rehabilitation, the final step of diagnosis or categorisation is not always that obvious.[4] There may be diverse categories such as functional deficits, dysphagia or aphasia, and movement deviations.[4]
- Consider the following example[4]:
- 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.[13] In the example above an example of hypothetico-deductive reasoning being used by the occupational therapist may look like this (Table 2)[4]:
- Consider the following example[4]:
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[edit | edit source]
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.
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.
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[edit | edit source]
Hypothesis-Oriented Algorithm for Clinicians II (HOAC II)[edit | edit source]
The Hypothesis-Oriented Algorithm for Clinicians II (HOAC-II)[14] 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: The Hypothesis-Oriented Algorithm for Clinicians II (HOAC II): a guide for patient management.[7]
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[edit | edit source]
- Collect initial data[7]
- information from referring professional
- medical record of patient
- observation before formal evaluation
- patient history
- Generate patient-identified problems (PIPs) list[7]
- 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[7]
- 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[7]
- Add non-patient-identified problems (NPIPs) to the problem list[7]
- 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[7]
- Refine the problem list[7]
- Establish goals for problems[7]
- Establish a testing criteria for every existing problem and / or establish predictive criteria for anticipated problems[7]
- Establish a plan to reassess the testing and predictive criteria and establish a plan to assess the status of problems and goals[7]
- Plan intervention strategies based on hypotheses and anticipated problems[7]
- Implement the intervention tactics[7]
Example of Using the HOAC-II and Hypothetico-deductive Reasoning[edit | edit source]
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.
HOAC-II Framework Steps[7] | Clinical reasoning |
---|---|
Collect initial data |
|
Patient-identified problems (PIPs) |
|
Formulate examination strategy | Initial hypotheses constructed from available data and patient-identified problems
Planned examinations
|
Conduct the examination, analyse data, refine the hypothesis and additional examinations |
|
Non-patient identified problems (NPIP) | Clinicians identify these problems:
|
Hypotheses for existing problems |
|
Refine the problem list |
|
Establish goals for problems |
|
Establish testing criteria for every existing problem |
|
Plan intervention strategies based on hypotheses |
|
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[edit | edit source]
Aspects of narrative reasoning include the following:
- focuses on telling and interpreting stories to guide patient-centered clinical practice[15]
- requires the clinician to make inferences about motives of others based on observations[16]
- 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[17]
- often heard through discussions regarding a clinical encounter[8]
- retelling the encounter naturally reveals the interpretation of the patient's intentions, goals and motives[8][10]
Example of Using Narrative Reasoning in Rehabilitation[edit | edit source]
The following is a case scenario focusing on narrative reasoning to provide patient-centered care.
Case example
Meet Joe Blogs, a 65-year-old retired teacher who was diagnosed with Parkinson's disease two years ago. Joe lives with his wife, Janey, and they have three adult children who visit often. Joe's primary concern is maintaining his independence and continuing to engage in his favourite hobbies, which include writing poetry and attending local poetry readings.
Through discussions with Joe, the multidisciplinary rehabilitation team learn that Joe's tremors and rigidity make it difficult for him to write legibly, causing frustration and discouragement. He also expresses concern about his ability to attend poetry readings due to his soft voice and difficulty with mobility.
Considering Joe's story, the team might suggest the following interventions:
- Adaptive writing tools such as voice-to-text software or a specialised pen that can help reduce the impact of tremors on his writing. This will allow Joe to continue expressing himself through poetry.
- Voice therapy: A speech and language therapist can help Joe improve his voice projection and clarity, enabling him yo continue participating in poetry readings.
- Mobility aids: The physiotherapist and occupational therapist can assess Joe's mobility needs and recommend appropriate aids, such as a walker or a cane, to ensure he can safely navigate the venues where poetry readings are held.
- Home modifications: The rehabilitation team can evaluate Joe's home environment and suggest modifications, such as installing grab bars or removing tripping hazards, to promote his independence and safety.
Through narrative reasoning, the team can better understand Joe's unique story and tailor interventions to his specific goals and values. By helping him to engage in the things he loves, his identity as a poet is recognised and that his desire for independence is central to his well-being. If Joe is resistant to using a mobility aid, for example, the rehabilitation team can explore his concerns and work with him to find a solution that aligns with his self-image and preferences.
Narrative reasoning allows clinicians to see a patient as a whole person with a unique story, instead of only focusing on the medical diagnosis. When clinicians understand a patient's perspective, they are able to develop a more personalised and effective rehabilitation plan that will improve a patient's quality of life.
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- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 Abrandt Dahlgren M, Valeskog K, Johansson K, Edelbring S. Understanding clinical reasoning: A phenomenographic study with entry-level physiotherapy students. Physiotherapy Theory and Practice. 2022 Nov 18;38(13):2817-26.
- ↑ Roine M, Sjögren T, Korpi H, Jäppinen AM, Karvonen E. Physiotherapists’ clinical reasoning in examination of clients with low back pain in direct access practice: a theory-driven qualitative content analysis. European Journal of Physiotherapy. 2023 Jun 19:1-0.
- ↑ Duong QH, Pham TN, Reynolds L, Yeap Y, Walker S, Lyons K. A scoping review of therapeutic reasoning process research. Advances in Health Sciences Education. 2023 Oct;28(4):1289-310.
- ↑ 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 Hoffman, L. Clinical reasoning processes for examination and evaluation. Course. Plus. 2024
- ↑ Yazdani S, Hosseinzadeh M, Hosseini F. Models of clinical reasoning with a focus on general practice: a critical review. Journal of advances in medical education & professionalism. 2017 Oct;5(4):177.
- ↑ Schaaf RC. Creating evidence for practice using data-driven decision-making. The American Journal of Occupational Therapy. 2015 Mar 1;69(2):6902360010p1-6.
- ↑ 7.00 7.01 7.02 7.03 7.04 7.05 7.06 7.07 7.08 7.09 7.10 7.11 7.12 7.13 7.14 Rothstein JM, Echternach JL, Riddle DL. The Hypothesis-Oriented Algorithm for Clinicians II (HOAC II): a guide for patient management. Physical Therapy. 2003 May 1;83(5):455-70.
- ↑ 8.0 8.1 8.2 Haines D, Wright J. Thinking in stories: Narrative reasoning of an occupational therapist supporting people with profound intellectual disabilities’ engagement in occupation. Occupational Therapy In Health Care. 2023 Jan 3;37(1):177-96.
- ↑ 9.0 9.1 Mattingly C. The narrative nature of clinical reasoning. The American Journal of Occupational Therapy. 1991 Nov 1;45(11):998-1005.
- ↑ 10.0 10.1 Mattingly C. In search of the good: Narrative reasoning in clinical practice. Medical anthropology quarterly. 1998 Sep;12(3):273-97.
- ↑ 11.0 11.1 Milota MM, van Thiel GJ, van Delden JJ. Narrative medicine as a medical education tool: a systematic review. Medical teacher. 2019 Jul 3;41(7):802-10.
- ↑ Cruz EB, Caeiro C, Pereira C. A narrative reasoning course to promote patient-centred practice in a physiotherapy undergraduate programme: a qualitative study of final year students. Physiotherapy Theory and Practice. 2014 May 1;30(4):254-60.
- ↑ Madden RH, Bundy A. The ICF has made a difference to functioning and disability measurement and statistics. Disabil Rehabil. 2019 Jun;41(12):1450-1462.
- ↑ Rothstein JM, Echternach JL, Riddle DL. The Hypothesis-Oriented Algorithm for Clinicians II (HOAC II): a guide for patient management. Physical Therapy. 2003 May 1;83(5):455-70.
- ↑ Nesbit KC, Randall KE, Hamilton TB. The development of narrative reasoning: Student physical therapists’ perceptions of patient stories. Internet Journal of Allied Health Sciences and Practice. 2016;14(2):3.
- ↑ Higgs J, Jensen GM, Loftus S, Christensen N. Clinical Reasoning in the Health Professions. Edinburgh: Elsevier. 2019
- ↑ Koufidis C, Manninen K, Nieminen J, Wohlin M, Silén C. Representation, interaction and interpretation. Making sense of the context in clinical reasoning. Medical Education. 2022 Jan;56(1):98-109.