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 Step-By-Step Guide
Tips and Traps
Resources
Step-By-Step Guide
How to Choose Diagnostic Tests
As the next step in assisting Dr. Shah with Jenny Anderson’s case, you will be responsible for advising Dr. Shah on what diagnostic tests that you think should be performed at this time.
As you know, Jenny Anderson was already given a series of foot and ankle x-rays when she came into the hospital two weeks ago with an acute injury. Dr. Chang selected x-rays as a reasonable and affordable first step in investigating her ankle injury. This was appropriate, as x-rays are simple to do, but can reveal a substantial amount of information. At that time, Jenny had negative x-rays, indicating no fractures. However, her pain and functional limitations have continued, and her condition has not improved greatly. Therefore, more investigation must be done to pinpoint the cause of her symptoms. Use the step-by-step instructions that follow to choose the appropriate diagnoses for further investigation and to choose tests which will help to confirm or disconfirm the diagnoses.
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:
- Additional Tests Form- This is the form that physicians at Lakeshore Hospital use to select which tests a patient will receive. In the first section, you will list the diagnoses you would like to test. In the second section, you will explain which tests you considered, which tests you chose, and why.
- In addition, you may refer to materials from the previous tasks, such as your Revised Differential Diagnosis from the last task, or Dr. Chang’s test selections in his Additional Tests Form from Case 1.
- Carefully review the email from Dr. Mendoza to become familiar with the goals of this task.
- Review the material about the processes physicians use to select diagnostic tests.
- Reread Step 4 of the Diagnosis and Treatment Process document: Test the diagnoses to confirm or disconfirm them. This section explains how a physician tests the diagnoses in the differential.
- For additional guidelines that physicians follow during this step of the diagnosis and treatment process, see Tips and Traps (above).
- Organize your team to complete the task.
• If you need a refresher on getting organized, refer to the step-by-step guide for Task 1.
Completing the Testing Form: Section A – Diagnoses Considered for Further Testing
When the patient first came into the hospital, Dr. Chang did not order tests for every diagnosis in her differential. In order to be practical, she investigated diagnoses for one of three reasons:
- The condition was a “must-treat” condition.
- The condition was very common.
- The condition could be tested inexpensively.
These are not the only criteria that dictate the diagnostic process, however, so you are now charged with revisiting this case.
- Decide which diagnoses you think deserve further testing at this time. To do this:
- Review the differential diagnosis that you created in Task 1, and note which diagnoses you listed as still under consideration.
- Separate these diagnoses into two further categories—those which were already subjected to some testing, and those which were never subjected to diagnostic tests beyond the manual exam.
- Review all diagnoses still under consideration. Ask yourself the following questions:
- Is this a condition that the patient is likely to have?
- Does this diagnosis match well with the picture of signs and symptoms presented?
- Does this diagnosis match well with the patient’s health history, risk factors and demographic profile?
- Does this diagnosis match well with the patient’s story about the onset of the problem and with the patient’s mechanism of injury?
- Is there little to no evidence that would contradict this diagnosis.
If the answer to many of these questions is yes, and there is a good amount of evidence pointing to this diagnosis, you have justification to go ahead with further testing to confirm or disconfirm the diagnosis.
- For the diagnoses which were already subjected to some testing, but are still under consideration due to inconclusive results, ask these additional questions:
- What test(s) were done previously and what were the results?
- What did you learn from the test(s)?
- Do you find these results sufficiently convincing? Why or why not?
- Might there be reason to repeat the same tests a second time?
- Do you think you’d be able to gather useful information about this diagnosis by ordering a new and different test (or tests)?
- Would ordering a more expensive and sophisticated test now be defensible? Why or why not?
- Based on your answers to the questions in Step 1 (above), fill in section A of the template with the diagnoses you would like to test now and your reasons for considering each diagnosis.
Completing the Testing Form: Section B – Tests for Each Diagnosis
- List the diagnoses that you chose in Section A in the first column of Section B. They should be ranked from most to least likely, as in the differential.
- Review what you know and what you still need to know about the patient with regard to each diagnosis. Decide what pieces of information, if any, are crucial for you to find out now.
- Investigate the different tests available that will help you to obtain the information you need. Some of the tests relevant to the diagnoses in this case include X-rays (radiographs), MRI, bone scan, stress X-rays, and CT scans.
- Use the DATA (Diagnosis and Treatment Archive) to find tests that help in determining each diagnosis. For each test, consider:
- What is this test best at revealing?
- When is this test most effective at revealing the information?
- Are there any other tests that are better at revealing this information?
- Are there any health risks associated with the test?
- What is the cost associated with the test, relative to other tests you might be considering?
- For additional ideas about which tests to order now, you may review Dr. Chang’s testing form from the initial visit (Additional Tests Form- Case 1, Task 3). Perhaps some of the tests that Dr. Chang considered but decided to postpone might be appropriate now. Subject these options to same the criteria that you are using for all tests.
- Decide which test, if any, will be best to order at this time.
- Remember, you should use the test with the least financial costs and health risks that will work sufficiently to give you the information you need.
- However, also keep in mind that since the patient’s problem has not resolved, there is more of a need now to come to a definitive diagnosis.
- If you determine that a test, while expensive and/or risky, is necessary, it is important to communicate well with the patient about the decision. In some cases, you may need the consent of the patient to proceed. This is called “informed consent.”
- Based on your decisions in the steps above, fill in Section B of the template for each diagnosis. Remember to address the topics in all four columns:
- Tests Considered
- Tests Recommended
- Purpose of Each Test Recommended
- Reasons for Not Recommending Other Tests
- Check to see that you completed all parts of the task.
Meeting to Exchange Feedback
- Meet with your cohort to discuss your findings and ideas. You will be assigned one or more sections of the form at the beginning of the meeting; your team will present your key ideas and lead the discussion of that section with the cohort.
- After incorporating any feedback you may have received during the cohort discussion, submit your work to your mentor. Be sure to save all of your work, regardless of whether you submit it to the mentor.
Tips and Traps
How to Choose Diagnostic Tests
- When treating patients in sports medicine, in the absence of a critical injury it is often the right choice to see what happens with mild or no intervention. However, if the patient has not improved significantly after a reasonable amount of time, physicians do become more aggressive in uncovering the source of his/her discomfort. This does not mean that waiting was the wrong choice; it simply means that there is more work to do to help the patient.
- When investigating a follow-up visit, physicians do balance the heightened importance of finding the correct diagnosis and relieving the patient's discomfort with the risks and costs of additional testing.
Additional relevant Tips and Traps may be found
in Case 1, Task 3: Critique of Additional Evidence.
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Diagnosis and Treatment Archive - Sports Medicine
What are the most common causes of ankle swelling and bruising?