A.

Clinical Reasoning Note

This can be found under the ASSIGNMENTS tab in SAKAI.

Overview:

Clinical reasoning is the main skill perfected in medical training. It involves assimilation of
information and statistically consideration of likely causes of symptoms. In medicine, this is
often in list format and not articulated in complete sentences. It is often in your mind as you
obtain the history and integrate that with the physical exam. By the end of medical training this
occurs seamlessly and quickly. Additionally, in 2012 the NBME changed the written notes for
the Step2CS exam to a clinical reasoning note.

The objectives for this brief assignment:

1. Familiarize yourself with the clinical reasoning format used on Step2 and for the FM
OSCE
2. Begin expanding the skills of choosing pertinent positives and negatives to order a
differential diagnosis. (This skill began in clinical pathology and ICR, but will need to be
put together clinically)

Instructions:

You may choose any patient you have seen during your Family Medicine rotation to do this
assignment. This is not meant to require hours of research. You may look at any quick database
for information you would use while seeing patients in the clinic. You do not need to research
the sensitivity and specificity of testing. Again, this is to prep you for the future use of notes like
this.
The clinical reasoning note while very similar is not the same as an encounter note. An
encounter note typically includes all of the information collected and often won’t include a
detailed differential discussion whereas the clinical reasoning note should include only the
subjective and objective information that is pertinent to your differential and subsequent further
evaluation. You may use bullets in lieu of sentences/paragraphs. The format for the note:

a. Subjective: CC, HPI w/ appropriate PQRST, pertinent positive and negative Past,
Social, Family Hx and ROS.
b. Objective: Vital signs, pertinent positive & negative physical findings. Preliminary
lab/rad results may also be included
c. Differential: List top 3 diagnoses. List the supporting and negating factors for each.
d. Further Evaluation: What labs, radiology, consults do you want. In a logical diagnostic
work-up, these should match your differential as a means to better define the problem.

Grading Criteria:

2 points Assignment complete. Concise subjective summary of the patient. Complete and
pertinent physical exam findings reported. Appropriate and reasonable
differential diagnoses offered and discussed with supporting and negating factors
for each differential. Logical plan.
1 point Assignment complete. One or more issues with any of the above criteria.

0 points Assignment not done or all portions incomplete.