Clinicians formulate a differential list of diagnoses within
seconds of meeting a patient:-
55 year old woman with chest pain. No trauma. Pleuritic.
Even on such brief information it is enough to flag a list
of differentials up in your mind. The experienced
clinician then uses different questions and elements of
the examination toi determine which is these is the
more likely.
It is very odd then that we teach our medical students
to take a full hx, do a full examination and then, and
only then formulate a differential diagnosis. We should
start teaching people to hone their natural way of
thinking rather than to artificially teach an abstract way.
Sackett addresses this well in Clinical epidemiology: a
basic science for clinical medicine. It is often very
interesting to watch experienced clinicians take hx's.
They do the above (focused questions to make
differentials more or less likely) but sometimes seem to
go back into medical student mode (e.g. asking the 7
questions you are told to ask about any pain). If you
ask them why it is often because they can't think of
what to ask next and just want to keep the patient
talking.
Another (mis)quote from Sackett:
Everyone should know how to take a full hx and exam,
but no-one should ever do one.
Our speciality is centered around diagnosis. I believe
that we should all understand some of the theory
behind the clinical hx, exam and lots about diagnostic
testing (but there again I am biased).
Simon
>> -----Original Message-----
>> From: Rowley Cottingham [mailto:rowley@ROWLEYS-
HOST.COMPULINK.CO.UK]
>
>> I felt a bit chastened by this initially, but then
thought
>> about it. I don't think we ever fully examine a
patient.
>> Indeed, I teach the juniors
>> not to examine patients exhaustively; once a
management plan
>> is clear they should stop examining and
investigating, make sure the
>> patient is safe and refer or treat and send home.
>
>
>Well said, Rowley. 'No tests that don't alter
management' includes elements
>of clinical examination. Use your brain instead of
following pathways.
>'Problem Solving in Clinical Medicine: From data to
diagnosis' (P Cutler;
>Williams and Wilkins 1979- there may be a more
recent edition) covers this
>well- good diagnosticians refine with each question or
element of
>examination and add or remove error correcting
questions from their list
>until a diagnosis is reached rather than following a
rigid 'clerking' model.
>
>Matt Dunn
>
>
Simon Carley
SpR in Emergency Medicine
http://www.bestbets.org
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