Some thoughts on diagnostic reasoning

Yesterday I tweeted about our success in making some worthwhile diagnoses in the category of unusual presentations of common diseases. As I consider these successes, the principles of diagnostic aggressiveness become central to my thoughts. For arguments sake let’s imagine three types of diagnostic reasoning. The first occurs when there is no diagnosis but we know something is wrong. These patients generally require a broad differential and much clinical thought. We often go back and collect more history, repeat the physical exam and think broadly about labs and imaging. We often need several consultants and often biopsies. The second version includes the majority of patients – a straightforward diagnosis. We need not spend much time on diagnosis unless the respond to treatment raises warnings that we might have the wrong diagnosis. The third version involves patients whose presentation involves some subtleties. These are the patients who too often do not stimulate diagnostic curiosity. Yet, when we pay attention to the subtle clues, we often reopen the diagnostic process. The most fulfilling diagnoses that I and my teams have made occur in this latter category. This fits an Osler quote, “The value of experience is not in seeing much, but in seeing wisely.” The astute diagnostician observes a lab, or physical finding, or imaging finding that does not fit the assumed diagnosis, and has courage to question that diagnosis. Sometimes the trigg...
Source: DB's Medical Rants - Category: Internal Medicine Authors: Tags: Medical Rants Source Type: blogs