Clinical reasoning requires making judgments based on evidence.
Part 1: Subjective and Objective Data
1. List the subjective data noted in the following case history that follows:
Case Study
Mr. Jones is a 49 year-old male admitted yesterday with complaints of chest pain. His healthcare provider (HCP) ordered the following studies: electrocardiogram, chest x-ray, complete blood count and basic metabolic panel, magnesium level.
Results of these studies were just posted on the electronic health record (EHR). Whey you talked with Mr. Jones, he states "I feel much better today, no more pain. It is a relief to get rid of that discomfor." You think he appears a little tired or weary; he seems to be talking slowly and sighs more often than you think is normal. He denies being weary. His vital signs (VS) are: T- 98.6, P-76 (regular), R- 22, BP 140/90, O2 sat - 96%.
2. List the objective data noted in the preceding case history (what information is observed?).
Part 2: Cues and inferences
1. List the cues in the case history
2. List the inferences that you might make about the cues you identified.
Part 3: Validating data
1. Decide how valid the cues and inferences that you identied
2. Identify some ways you could validate your cues and inferences