臨床推論のムーブ 暫定版"GESTALT"

Generate a hypothesis. (inductive phase)
例）

• This patient's age, sex and presentation suggest a pathologic process with organ involvement.
• The first things that come to mind are the usual causes of respiratory distress, such as pneumonia, congestive heart failure, or a pulmonary embolus.

Explore the worst case scenario.
例）

• ... are among the “must not miss” diagnoses and should be ruled out.
• ... are not compelling possibilities with this history, but they should be kept in mind.

Sharpen the hypothesis.
例）

• The finding narrowed the broad differential diagnosis.
• The finding leads me to broaden my differential diagnosis.

Tweak the probability
例）

• The presence of ... reduces the likelihood of ...
• The absence of ... raises the possibility of ...

Ask for further information (Proposal of further investigation, Question ... )
例）

• I would also check for the presence of antineutrophil cytoplasmic antibodies and consider a sural-nerve biopsy.
• To look for other possible sources of sepsis, I would order an abdominal CT scan and an echocardiogram.

List some hypotheses in order of priority.
例）

• My three major considerations at this point are ...
• The three most likely diagnoses at this point are ...

TEST the hypothesis (deductive phase) - Timeline review, Explain the findings?, Simple adequately?, Theory-based?
例）

• Because her diagnosis continues to elude me, I would also carefully review her previous test results to try to discover something that is obvious only with hindsight.
• Rheumatoid arthritis could explain subacute symmetric arthralgias in a young woman, but severe pulmonary or cardiac manifestations early in the disease course would be unusual.
• Occam's razor is an issue here — that is, will one diagnosis explain all the findings?
• The pathological findings are consistent with the presence of arteriopathy, venulopathy, and secondary hemorrhagic infarcts; nothing suggests necrotizing vasculitis