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 Step-By-Step Guide
Tips and Traps
Resources
Step-By-Step Guide
How to Revise a Differential Diagnosis at a Follow-up Visit
Along with your resident, Dr. Shah, you will observe Jenny Anderson at her follow-up visit two weeks after the injury occurred. You will collect any new information about the patient’s ankle problem, and revise the differential diagnosis accordingly. At this visit, Dr. Shah interviews the patient and does the physical examination, while you have the opportunity to watch closely. Your job is to develop the new differential diagnosis. To do this, you will use the new information provided by both the patient and your colleague and integrate this with older information in the patient’s file written by Dr. Chang.
Getting Started
- Get prepared to do your work in this task.
- Go to the email sent to you by Dr. Mendoza, and download the attachments. You will need the following throughout the task:
- Video of the Follow-up Interview and Examination - You will use this video to closely observe everything that took place during Jenny’s follow-up visit.
- Patient Interview and Physical Examination Form - This form contains Dr. Shah’s notes recording the findings from the follow-up visit.
- Differential Diagnosis Form (blank) - This is a blank template you may use to develop your updated differential diagnosis for Jenny Anderson.
- In addition, you are free to refer back to any Case 1 templates or other materials that you believe will help you. It would be extremely beneficial to look over your Critique of the Revised Differential Diagnosis from Case 1. You also may want to look back at Dr. Chang’s notes in the original Patient Interview and Examination Form (Case 1, Task 1) to review some of the data that was collected at the earlier visit.
- Gather any research or critique notes that you developed in Case 1, as you will have reason to refer back to them in this case.
- Carefully review the email from Dr. Mendoza to become familiar with the goals of this task.
- Briefly review the attachments to the email to familiarize yourself with the contents of each.
- Review the material about the methods physicians use to create and revise a differential diagnosis.
- See the material on Differential Diagnosis in the Resources (above).
- Reread section 4 of the Diagnosis and Treatment Process document: Test the first diagnosis to confirm or disconfirm it. This section explains how a physician revises the differential diagnosis.
- For additional guidelines that physicians follow during this step of the diagnosis and treatment process, see the Tips and Traps (above).
- Organize your team to complete the task.
- It is up to your team to decide how to organize the work in this task. You may want to use the strategy of “divide and conquer” so that team members split up the work, or you may want to help each other cover the same ground. If you decide to divide the work, it is important for you to meet regularly to touch base on your progress and share the information you have found. Regardless of how you decide to break up the work, each team will need to submit a single, unified document to the mentor for review.
- For help with working as a team, managing your time, and managing a project (managing the work in a task is similar to managing a project), see the sections on Teamwork and Project Management in the General Skills Resources in the left menu.
- Organize yourself to complete the individual portion of the task- creating a new differential diagnosis for Jenny Anderson.
- To create your own differential, you may start with the blank Differential Diagnosis Form and fill in your answers; as you do so, you may enter information from Dr. Chang’s older form if you agree with it and think it is still valid.
- Alternatively, you may start with Dr. Chang’s document from Case 1 and edit it, adding and subtracting information and changing the ranking of the diagnoses as you see fit. Choose the method which will work better for you.
- You will work with the same list of diagnoses that Dr. Chang originally named. However, for the purposes of this task, you will divide the diagnosis of Lateral Ankle Sprain into the three degrees of sprain—Type I, Type II, and Type III. Each one should be entered on the differential as a diagnosis of its own. You may have to review or do some research in the Resources (above) to know the differences between the three types.
- Be prepared to change the ranking of the diagnoses to fit your analysis of the data.
- Also, you may change which diagnoses are under consideration, so that diagnoses which Dr. Chang ruled out will now be considered, and diagnoses which Dr. Chang considered will now be ruled out.
Revising the Differential Diagnosis
- First, note any new findings that have a bearing on Jenny’s Anderson’s case.
- Review the video and notes from the follow-up visit, and note any significant findings. Significant findings encompass anything abnormal, including:
- The symptoms noted by Jenny and her mother
- Were any symptoms mentioned during the follow-up visit?
- Were any important details given related to the symptoms?
- Were any of these symptoms lingering? Have they improved or worsened?
- How have the symptoms responded to treatment? (Note: This is a particularly important question, since a failure to respond to treatment may indicate a problem with either the diagnosis or the treatment prescribed.)
- Are there any new symptoms? If so, what are they?
- Signs the physician observed in the physical examination
- In what anatomical area(s) were abnormalities found, if any?
- In what anatomical area(s) was pain localized? (You may write your answer in words; it may also help to sketch a picture indicating where significant pain and other symptoms were found.)
- What normal functions or movements were affected? Describe how the patient’s functioning was different from normal functioning.
- What structures control these movements in a normally functioning patient?
- Why might the functioning of these structures be limited or changed in this patient?
- For information about the key structures of the ankle, review the materials on Ankle and Foot Anatomy in the Resources (above).
- Integrate these new findings with the data that was gathered previously about Jenny’s problem.
- Review relevant items from Jenny’s general health history and patient profile, including:
- health history
- demographic information (age, gender, hometown, etc.)
- lifestyle and habits
This information will help you to determine Jenny’s risk factors for particular conditions and whether she is more likely to have some conditions rather than others. Also, if the patient has any prior health problems, it will help to ensure that you do not prescribe any treatment that is not indicated (in other words, unhealthy or unsafe) for a patient like her.
- Review the patient’s story from the first (acute) visit. What mechanism of injury was suggested in the history?
- If you can identify how the patient’s injury occurred and what abnormal motion or action took place at the time of the injury, you can use this information to help develop and rank the differential.
- Since certain motions, actions, or events will cause particular kinds of injuries, it will be helpful to compare the patient’s story with the typical one for each diagnosis.
- Review the test results in the patient’s file. Were there any significant positive or negative results from early tests?
- Do you find these results sufficiently convincing? If so, you can base a decision to include or omit a diagnosis on these test(s).
- Do you have any reason to think that the test results may not have been completely valid or conclusive?
- For example, some tests may not work well in revealing a particular diagnosis when the patient still has acute symptoms; they may need to be repeated later to get accurate results.
- You may think that the tests were not sensitive enough in general to be conclusive in detecting a particular condition. In the next task, you’ll have the opportunity to order a more sophisticated test (or tests) if you feel they are warranted.
Note: While you will need to cover all of the sub-steps that follow in Step 3 and Step 4, you can do so in any order that makes sense to you.
- Organize your evidence in the Differential Diagnosis form.
- Fill in the new evidence that you have for and against each diagnosis.
- To do this, use the new information that you gathered in step one (above). Each piece of data gathered in the latest interview and examination may be able to serve as evidence for—or evidence against—a certain diagnosis. For each finding, ask:
- Is this finding consistent with one or more of the diagnoses? If so, enter the finding as evidence for the diagnosis or diagnoses.
- Is this finding inconsistent with, or would it contradict, one or more of the diagnoses? If so, enter the finding as evidence for the diagnosis or diagnoses.
- In trying to make these matches, pay particular attention to the way the symptoms and signs have developed over time. Does this match the typical progression of symptoms and signs in a patient with a given diagnosis?
- If you are not sure, you may need to do some research to find out more about the progression of symptoms that are typical for a diagnosis. What would you expect from a typical patient with the condition, if they are treated? If they go untreated?
- You may also complete this substep in the opposite order, that is, look first at each diagnosis, and find the typical presentation of symptoms after 2 weeks with each condition. Then see if you have any findings for Jenny Anderson that would support or contradict this picture.
- Review the evidence that came from the previous patient visit, as well as the analysis of the previous doctor (Chang). Decide whether you think the evidence is still valid. Revise the evidence in the differential form accordingly.
- To do this, look back at your answers to the questions posed in step 2 (above). Highlight any details related to the patient’s health history, demographic profile, history of the present illness, or testing record, that you think are still valid. Enter these details as evidence for or against each diagnosis, as appropriate.
- Remove or change any details that you think are no longer valid or sufficient as evidence in the updated differential.
- If you think the previous physician may have interpreted the meaning of various findings incorrectly, revise the analysis.
- For example, perhaps a negative test result was used to completely rule out a diagnosis. You may not disagree with the reading of the test, but you may disagree with what the physician said it meant—that the diagnosis should be ruled out. If so, you may reinstate the diagnosis in column titled “Still Under Consideration?”
- Similarly, you may have disagreed with the previous physician’s decision to keep a particular diagnosis under consideration. If that is the case, and you feel you have sufficient evidence to do so, rule out the diagnosis now. Write your evidence against the diagnosis, and write your rationale in the last column
- It may help you to look back at the critiques of Dr. Chang ’s work and reasoning that you and your teammates completed in Case 1.
- Revise the ranking of the diagnoses in the differential.
- Move all of the diagnoses that are no longer under consideration to the bottom of the list.
- Rank all of the diagnoses that are still under consideration above the ones that are not. Order them from most likely to least likely, based on your evidence.
- In order for a diagnosis to rank high on the list, it should have many pieces of evidence supporting it and few to none against it.
- A lower-ranked diagnosis will have more pieces of evidence against it and fewer supporting it. However, you must have enough evidence (or enough “reasonable doubt” as they say in the law) in order to keep it on the list for further exploration.
- Make a careful decision about the diagnosis for the number one position; this will be your working diagnosis. Check your choice against the following questions:
- Is there a close match between the findings for this patient and a typical case of the condition?
- Were the test results consistent with the diagnosis? Do you think you might be able to obtain new, additional test results to support this diagnosis?
- Were there any findings that were not consistent with the diagnosis?
- Is this the most likely diagnosis for this patient, given the patient’s risk factors and the history of the present illness?
- Check to make sure you have completed the entire form and that all of your work makes sense.
Meeting to Exchange Feedback
- Meet with your teammates to discuss your findings and ideas. Take some time for each person to share highlights of his/her work.
- Come to a consensus on the differential diagnosis.
- As a team, create a differential diagnosis that you can agree upon, to submit as a group deliverable.
- To help you, see the resources on Teamwork, especially the articles on collaborative group work and collaborative writing, in the General Skills Resources in the left menu.
- Submit both your individual work and your team document to your mentor. Be sure to save all of your work, regardless of whether you submit it to the mentor.
Tips and Traps
There are no new Tips/Traps for this task. For guidance on revising a differential diagnosis, refer back to Tips and Traps for Case 1: Tennis Twist. The Critique of Differential Diagnosis task is relevant here.
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Diagnosis and Treatment Archive - Sports Medicine
What is a differential diagnosis?