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This is a lecture by Dr. Zach Sturges from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.

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The practice of anesthesia and sedation continues to expand beyond the operating room and now includes the gastroenterology suite, magnetic resonance imaging suites, and the cardiac catheterization laboratory. Non-anesthesiologists frequently administer sedation, in part because of a lack of available anesthesiologists and economic aspect, which emphasizes the safety of sedation. The Joint Commission International (JCI) set a standard responding to this issue indicating that qualified individuals who have drug and monitoring knowledge as well as airway management skills can only administer sedating agents.

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C H A P T E R 1 Clinical reasoning, evidencebased practice, and symptom analysis Basic health assessment involves the application of the practitioner’s knowledge and skills to identify and distinguish normal from abnormal findings. Basic assessment often moves from a general survey of a body system to specific observations or tests of function. Such an approach to assessment and clinical decision making uses a deductive process of reasoning. For example, a specialist examining a patient with known hyperthyroidism would conduct a physical examination to test for deep tendon reflexes. Brisk or hyperreflexic reflexes would lead the practitioner to conclude that a hyperthyroid state is a likely cause of these findings. This would greatly narrow the choices of diagnostic tests and treatment decisions. Advanced assessment builds on basic health assessment yet is performed more often using an inductive or inferential process, that is, moving from a specific physical finding or patient concern to a more general diagnosis or possible diagnoses based on history, physical findings, and the results of laboratory and diagnostic tests. The practitioner gathers further evidence and analyzes this evidence to arrive at a hypothesis that will lead to a further narrowing of possibilities. This is known as the process of diagnostic reasoning. Diagnostic reasoning Diagnostic reasoning is a scientific process in which the practitioner suspects the cause of a patient’s symptoms and signs based on previous knowledge. The practitioner gathers relevant information, selects necessary tests, makes an accurate diagnosis, and recommends therapy. The difference between an average and an excellent practitioner is the speed and focus used to arrive at the correct conclusion and initiate the best course of evidencebased treatment with minimum harm, cost, inconvenience, and delay. This expertise of the practitioner is acquired through knowledge and a skill set developed through experience in clinical practice. Repeated practice with real cases helps to develop memory schemes for relating clinical problems and store them in longterm memory. By using diagnostic reasoning, the practitioner is able to accomplish the following: • Determines and focuses on what needs to be asked, what data need to be obtained, and what needs to be examined • Performs examinations and diagnostic tests accurately • Clusters all pertinent findings • Analyzes and interprets the findings • Develops a list of likely or differential diagnoses The diagnostic process The primary care context The process of assessment in the primary care setting begins with the patient or caregiver stating a reason for the visit or a chief concern. Most visits to primary care providers involve concerns or symptoms presented by the patient, such as an earache, vomiting, or fatigue. The initial evidence is collected through a patient history. Demographic information, such as gend ...

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