Diagnosis and Treatment Process

This document describes a process that health care professionals typically use (and recommend you use) to diagnose what is wrong with their patients, and to develop treatment plans to help them. If you choose to deviate from this approach as you consider patients’ or clients’ problems, you should note that you are doing so and keep track of your chosen approach, not only so you can explain it to others, but also so you can determine what is the most efficient and effective method for you.

There is a myth that diagnosis is a process of ruling out every possible alternative condition (problem to be treated), leaving only one possibility that must be correct. Health care professionals use a process that is slightly different, in which real-world constraints enter into their decision making. Most notably, real-world practitioners strive to balance the costs and risks of performing various tests with the desire to achieve the greatest degree of accuracy in their diagnoses (and ultimately the success of their treatment plans). They also want to determine an appropriate treatment plan as quickly as possible.

The table below explains how to do this diagnostic process, as well as how to develop a treatment plan.

Step	Description
1. Determine available and relevant clinical findings and risk factors.	When trying to figure out what is wrong with a patient, the first step is to determine all relevant indicators of a problem, including both clinical findings and risk factors. “Clinical findings” refer to a compilation of: · signs (objective, outwardly-visible indications of a medical problem) · symptoms (subjective reports by patients of what they are experiencing) · and test results (the outcomes of one or more diagnostic tests beyond the standard physical exam, which the practitioner interprets to help make a diagnosis). “Risk factors” refer to characteristics of the patient, or the patient’s lifestyle, that can cause, contribute to, or suggest possible medical problems; it is not enough to consider clinical findings alone. These factors might include gender or age, which the patient cannot control, or behaviors like activity level, diet, or smoking. Practitioners need to consider a patient’s risk factors in conjunction with other clinical findings to be thorough in formulating an accurate diagnosis and appropriate treatment plan. Easy and inexpensive first steps Start by having a basic conversation with your patients to determine their symptoms, or main reason(s) they have come to you. You can learn a lot by just talking to your patients and being a great listener. If your patient cannot communicate with you, try to ask the person who brought them to you what they can tell you about the patient. You should then examine your patient to identify presenting signs. When you look for signs, scan the patient for any abnormalities—any outwardly visible conditions, confirmation of issues that the patient reports, or known clinical findings from prior examinations and tests. If you don’t have enough information from the signs and symptoms to adequately consider possible causes, then you can also use relatively low-cost, low-risk tests to collect additional information. Depending on the field in which you are practicing, there may be standard protocols or batteries of tests.
2. Hypothesize all of the possible causes of the patient’s clinical findings.	This set of possible causes is referred to as the differential diagnosis. It is a list of possible causes (diagnoses) for the most salient (conspicuously abnormal, in this case) clinical findings you have learned about so far. When you do not know what may have caused the clinical findings or to which problems the risk factors may contribute, you need to do research to find out. To start generating your differential, research each clinical finding and risk factor to find out which diagnoses they suggest.
3. Prioritize your differential.	Put any “must-treat” diagnoses at the top of the list; must-treat diagnoses are conditions so potentially severe and time-critical that they cannot be missed. Order the remaining diagnoses from most likely to least likely, insofar as you can determine this from your research. (Experienced clinicians typically rely on their studies and firsthand experience to estimate likelihood.)
4. Test the first diagnosis to confirm or disconfirm it.	Your goal now is to figure out which diagnosis (or diagnoses, in some cases) in your differential is the correct diagnosis, and during the process, to identify any other diagnoses that you might have left out of your differential (which you should also consider). To do this, begin by researching the first diagnosis in your prioritized differential and determine which additional clinical findings (beyond those you already observed) and risk factors are likely to be present in your patient to confirm or disconfirm the diagnosis. Then, ask the patient the relevant questions and perform the necessary examinations and tests to determine whether your patient does or does not present those additional findings that would tend to confirm the diagnosis. Note that you should choose tests based not only on the information they might yield but also on their costs and potential risks. · As you gather each new piece of evidence, revisit the diagnosis you are currently considering, and ask yourself the following questions: o Does the evidence tend to confirm or disconfirm the diagnosis? (Note that some clinical findings must be present to confirm a diagnosis, while others, though perhaps common for a diagnosis, may not always be present.) o Does some evidence suggest that new causes (potential diagnoses) should be added to the differential or that the differential should be reordered (with another diagnosis now being considered most likely)? If so, revise your differential. If your evidence tends to disconfirm the diagnosis you are testing, you might decide that this diagnosis is still possible, but less likely. In that case, you may choose to give it a lower ranking in your differential, in which case you will return to it if you disconfirm other, now more likely, diagnoses. Each time you reorder your differential, or move from the first diagnosis to the next in the list, continue the diagnosis process with Step 3 and repeat the remaining steps until you believe you have successfully confirmed your diagnosis to the degree it matters (meaning, to the degree you will be able to treat your patient appropriately). · If the patient shows a sufficient set of the key findings related to the diagnosis you are considering, then you successfully confirmed the diagnosis. (This means that all of the required clinical findings are present and that some additional common, but not required, findings are present as well.) In situations where accuracy is critical, such as prior to embarking on a painful or risky treatment, further examination and testing may be necessary to confirm the diagnosis and increase your confidence – but you may still not be 100% certain in some cases. Diagnoses do not always present in “textbook form.” Some findings may indicate a diagnosis only some of the time (e.g., it could be the case that there is a 60% chance of seeing a certain symptom for a particular diagnosis). This means that you can only make your diagnosis to some reasonable degree of certainty. · Note: Sometimes, such as instances where time is of essence and tests are risky and/or costly, but where treatment is not risky, the best “test” is to see how the patient responds to treatment. This is called a “therapeutic test.” Therapeutic tests can be used when the practitioner has a reasonable idea of what the proper diagnosis is and what an appropriate treatment could be. The approach is to administer the treatment and see if it works. o If, after receiving the treatment, the patient improves, then the doctor can assume that the treatment was successful (although the patient should be carefully monitored to ensure that symptoms haven’t just been temporarily alleviated by the treatment or by the natural fluctuation of symptoms typical of a given condition). o If the patient’s situation deteriorates, the treatment’s failure can provide additional information about the cause(s) of the condition. Clearly, in this case, the standard diagnostic process must continue, or another reasonable treatment must be tried.
5. Develop a treatment plan (and/or prevention plan)	Once you have determined the diagnosis, or set of diagnoses, you want to treat, it is time to develop a treatment plan. It is possible for a treatment plan to address more than one diagnosis at a time. A treatment plan may comprise several components, each contributing to various aspects of the diagnosed problems. In addition, treatment plans should address critical risk factors that have not yet become a problem to be treated. Treatments that address risk factors may help prevent problems from developing. For example, stabilizing a weak joint with an elastic bandage during exercise may prevent injury; eating a well-balanced diet may prevent nutritional deficiencies. You will need to do research to determine an appropriate treatment plan for each diagnosis and risk factor. When more than one treatment is possible, the clinician must pick the best option based on: · costs (monetary and risk) and benefits · patient characteristics (e.g., age, gender, mental and/or physical ability to comply with a treatment regimen) · patient lifestyle factors (e.g., schedules, dietary restrictions, other issues related to convenience for the patient)
Note: The process described above focuses on the exploration of a patient’s presenting symptoms. Many practitioners, as they diagnose, also consider the possibility that the patient may have other conditions related to the cause of their presenting symptoms. For example, a patient may report pain in one part of the body after a fall, but a practitioner is likely to examine the patient’s entire body in case other injuries occurred. On a real case, an expert practitioner might actually apply the above diagnosis process to multiple conditions at the same time, each potentially with its own differential, and therefore, resulting treatment plan.