Balancing technical rational with professional artistry: a case study in developing clinical reasoning for advanced care practitioners in primary care

Clinical reasoning is a critical skill for all healthcare practitioners. Learners aspiring to independent practice in primary care are further challenged where diagnostic uncertainty and patient preferences frequently intersect. This case study describes the assessment of a 72-year-old man presenting with unilateral leg swelling following total knee replacement. Although his Wells' score and a raised d-dimer suggested possible deep vein thrombosis (DVT), contextual evidence indicated that d-dimer levels remain elevated for weeks postoperatively. The patient also preferred to avoid unnecessary hospital visits. Through shared decision-making, safety netting and reflective clinical reasoning, the practitioner concluded that the presentation was most likely post-surgical swelling rather than acute DVT. This case highlights the challenges of balancing protocols with clinical judgement, the need to interpret diagnostic tests in context, and the value of communication skills in aligning management with patient preferences. Whilst the context of this case applies to the supervision of an advanced practitioner in primary care, the discussion considers implications for the education of all independent practitioners, particularly in consultation skills, interpreting evidence and clinical reasoning in the context of complexity.