Skip to content

A Systematic Approach

A draft framework for a clinical process and considerations when working through Case Based Learning.

1. History Taking

Patient-Centred Interviewing
Clinician-Centred Interviewing
Bias Check: Don't get tunnel vision.
  • Remember to not anchor on a diagnosis early.
  • Consider your developing problem list and differential diagnoses (Ddx) as you move into your physical exam.
  • "If it's not in your differentials, it won't be your diagnosis".

2. Physical Examination

Focused vs Comprehensive
Anatomic: *"System above, system below"*
Physiologic: *"Cause and effect"*

3. Problem Representation and Framing

Diagnostic Frameworks (Anatomic, Physiologic, Organ/System)
Illness Scripts (Key Features)
Problem Lists (Group vs Split)
    *Chief Complaint(s)*
    *Abnormal Findings*
    *Chronic Conditions*
    *Health Maintenance*

4. Hypothesis Generation

Summary Statement
Semantic Qualifiers

5. Differential Diagnoses (Ddx)

Probabilistic vs Prognostic
Threshold Model: Leading, Active, Must-Not-Miss, Excluded
Bias Check: Rule out before ruling in.
  • As a novice NP, consider "starting from the bottom" and ruling out must-not-miss diagnoses before focusing on the leading diagnosis.
  • Don't underestimate "Red Flags". Refresh your understanding of their definitions (e.g. metabolic decompensation in the initial pharmacological treatment of Type 2 Diabetes).

6. Diagnostic Testing and Evaluation

Test Selection
    Sequential vs Simultaneous testing
    Confirmation, Elimination, and Discrimination
    Positive vs Negative Predictive Value
    SNOUT & SPIN: Sensitivity, rule OUT. Specificity, rule IN.

7. Hypothesis Refinement and Diagnosis (Dx)

8. Plan of Care: Management

Patient Goals and Meaning Making  
Education  
Non-Pharmacological Therapies  
Pharmacological Therapies  
    Rational Prescribing  
Follow-up
References

1.  Altkorn, D. (2020a). A Model for Clinical Reasoning. In S. D. C. Stern, A. S. Cifu, & D. Altkorn (Eds.), Symptom to Diagnosis: An Evidence-Based Guide, 4e (Vol. 1–Book, Section). McGraw-Hill Education. accessmedicine.mhmedical.com/content.aspx?aid=1185661671
2. BC Provincial Mental Health and Substance Use Planning Council. (2013, May). Trauma-Informed Practice Guide. Centre of Excellence for Women’s Health. https://cewh.ca/wp-content/uploads/2012/05/2013_TIP-Guide.pdf
3. Beebe, S. L., McNelis, A. M., El-Banna, M., & Dreifuerst, K. T. (2024). Reflecting on diagnosis: The Metacognitive Diagnostic Reasoning Model©. Journal of the American Association of Nurse Practitioners, 36(12), 711–718. https://doi.org/10.1097/JXX.0000000000001018
4. Beer, L., Golub, L., & Smith, D. T. (2017). Diagnostic Reasoning and Decision Making. In S. C. McKean, J. J. Ross, D. D. Dressler, & D. B. Scheurer (Eds.), Principles and Practice of Hospital Medicine, 2e (Vol. 1–Book, Section). McGraw-Hill Education. accessmedicine.mhmedical.com/content.aspx?aid=1137605362
5. Corazza, G. R., Lenti, M. V., & Howdle, P. D. (2021). Diagnostic reasoning in internal medicine: A practical reappraisal. Internal and Emergency Medicine, 16(2), 273–279. https://doi.org/10.1007/s11739-020-02580-0
6. Croskerry, P. (2009). A Universal Model of Diagnostic Reasoning: Academic Medicine, 84(8), 1022–1028. https://doi.org/10.1097/ACM.0b013e3181ace703
7. Lu, C. M. (2025). Likelihood Ratios & Odds-Probability Conversion in Medical Decision-Making. In M. A. Papadakis, M. W. Rabow, K. R. McQuaid, & M. Gandhi (Eds.), Current Medical Diagnosis & Treatment 2025 (Vol. 1–Book, Section). McGraw-Hill Education. accessmedicine.mhmedical.com/content.aspx?aid=1209249935
8. Mashford-Pringle, A., & Shawanda, A. (2023). Using the Medicine Wheel as theory, conceptual framework, analysis, and evaluation tool in health research. SSM - Qualitative Research in Health, 3, 100251. https://doi.org/10.1016/j.ssmqr.2023.100251
9.  Parsons, A. S., Clancy, C. B., Rencic, J. J., & Warburton, K. M. (2022). Targeted Strategies to Remediate Diagnostic Reasoning Deficits. Academic Medicine, 97(4), 616–616. https://doi.org/10.1097/ACM.0000000000004244
10. Smith, S. K., Benbenek, M. M., Bakker, C. J., & Bockwoldt, D. (2022). Scoping review: Diagnostic reasoning as a component of clinical reasoning in the U.S. primary care nurse practitioner education. Journal of Advanced Nursing, 78(12), 3869–3896. https://doi.org/10.1111/jan.15414
11. Santana, M. J., Manalili, K., Jolley, R. J., Zelinsky, S., Quan, H., & Lu, M. (2018). How to practice person‐centred care: A conceptual framework. Health Expectations, 21(2), 429–440. https://doi.org/10.1111/hex.12640
12. Strong, E. (Director). (2020a, March 27). Diagnostic Frameworks and Differential Diagnoses (Vol. 2) [Video recording]. Strong Medicine. https://www.youtube.com/watch?v=RXfQTwpTusI
13. Strong, E. (Director). (2020b, March 29). Summary Statements and Semantic Qualifiers (Vol. 3) [Video recording]. Strong Medicine. https://www.youtube.com/watch?v=BLRFdX_NKRs
14. Strong, E. (Director). (2020c, March 31). Problem Lists (Vol. 5) [Video recording]. Strong Medicine. https://www.youtube.com/watch?v=fMug-dBvbmE&list=PLYojB5NEEakX7NBjs24Vd1dZaeOus3Uju&index=5
15. Strong, E. (Director). (2020d, April 5). Illness Scripts (Vol. 4) [Video recording]. Strong Medicine. https://www.youtube.com/watch?v=PlXSTcaenJc
16. Strong, E. (Director). (2020e, September 6). Test Selection (Vol. 6) [Video recording]. Strong Medicine. https://www.youtube.com/watch?v=22cP33v4--k
17. Strong, E. (Director). (2021, April 7). The Threshold Model of Clinical Decision-Making (Vol. 10) [Video recording]. Strong Medicine. https://www.youtube.com/watch?v=R1GGhYdOuxg
18. Strong, E. (Director). (2020, September 9). Clinical Prediction Rules (Vol. 7) [Video recording]. Strong Medicine. https://www.youtube.com/watch?v=lFiUlyDsvnk
19. Lippa, K. D., Feufel, M. A., Robinson, F. E., & Shalin, V. L. (2017). Navigating the Decision Space: Shared Medical Decision Making as Distributed Cognition. Qualitative Health Research, 27(7), 1035–1048. https://doi.org/10.1177/1049732316665347
20. Hansen-Ketchum, P. (2004). Parse’s Theory in Practice: An Interpretive Analysis. Journal of Holistic Nursing, 22(1), 57–72. SAGE Journals. https://doi.org/10.1177/0898010103261120 21. Strong, E. (Director). (2020, May 11). Cognitive Bias (Vol. 8) [Video recording]. Strong Medicine. https://www.youtube.com/watch?v=dwVHYKRYSuE
22. Dwamena, F. C., Fortin, A. H., & Smith, R. C. (2012). Chapter 3. Patient-Centered Interviewing. In M. C. Henderson, L. M. Tierney, & G. W. Smetana (Eds.), The Patient History: An Evidence-Based Approach to Differential Diagnosis, 2e (Vol. 1–Book, Section). The McGraw-Hill Companies. accessmedicine.mhmedical.com/content.aspx?aid=56850050
23. Fortin, A. H., Dwamena, F. C., & Smith, R. C. (2012). Chapter 4. Clinician-Centered Interviewing. In M. C. Henderson, L. M. Tierney, & G. W. Smetana (Eds.), The Patient History: An Evidence-Based Approach to Differential Diagnosis, 2e (Vol. 1–Book, Section). The McGraw-Hill Companies. accessmedicine.mhmedical.com/content.aspx?aid=56850134
24. Altkorn, D. (2020b). The Threshold Model: Conceptualizing Probabilities. In S. D. C. Stern, A. S. Cifu, & D. Altkorn (Eds.), Symptom to Diagnosis: An Evidence-Based Guide, 4e (Vol. 1–Book, Section). McGraw-Hill Education. accessmedicine.mhmedical.com/content.aspx?aid=1185661712
25. Eric Strong (Director). (2023, November 26). A Practical & Evidence-Based Physical Exam (Vol. 1) [Video recording]. Strong Medicine. https://www.youtube.com/watch?v=YggzI_EdJxk
26. Parse, R. R. (1992). Human Becoming: Parse’s Theory of Nursing. Nursing Science Quarterly, 5(1), 35–42. SAGE Journals. https://doi.org/10.1177/089431849200500109

Comments, Discussions, Links