Diagnostic Reasoning in Critical Care

When I was a nurse practitioner student, I wanted to do as many procedures as I could so that I could be proficient. My advisor told me, “I don’t care if you do a single procedure in school. I want you to focus on learning to think through a problem, formulate a differential diagnosis, and develop a treatment plan. I wasn’t really happy about that, as I really loved procedures and thought that’s where my focus should be. Making a diagnosis and formulating a treatment plan was easy. I thought.

Now, I teach ACNP students and find myself saying the same thing! I don’t care about students learning procedures. That’s one of the easiest parts of critical care to be honest. Of course it takes repetition to get good at procedures, but the critical thinking, that’s the tricky part. (Sure, there’s no reason that you can’t develop procedural skills and critical thinking.)

In fact, the really tricky part is making the diagnosis. You can look up treatment plans in UpToDate and at least get an idea of what to do. But making the diagnosis, that’s hard.

Recently, we had Andre Mansoor on the Critical Care Scenarios podcast to discuss the art of diagnostic reasoning. Dr Mansoor is the author of a great book on the subject, Frameworks for Internal Medicine. It is the best guide to diagnostic reasoning and differential diagnosis formation that I’ve read. I use it when I teach my ACNP students and when I create scenarios for simulation. In the podcast, Dr Mansoor goes through his thought process when approaching a patient and beginning to formulate a differential diagnosis. The book goes into even more detail, taking common presenting complaints, breaking them down and helping the practitioner narrow the list of possible problems based on the evidence collected in the history and physical exam, and then adding in other diagnostic studies.

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