Friday, May 17, 2013

Family Medicine: The Differential Diagnosis

What could be causing this?

This is a question that Family Physicians often ask as they interact with patients.  The list of possibilities that is actually considered is called the "differential diagnosis".

The list can be huge, but the active considerations are limited by the brains of the patient and physician and time, sometimes supplemented by decision aids in print or online.  Processing the possibilities via the history, physical and differential diagnosis is part of the fun of Family Medicine.

Added to this intellectual component is the human centered, relationship based engagement of patient and physician in a unique decision making dyad.  The roles assumed by the members of the dyad alter the process of engagement and decision making, affecting the differential diagnosis and the subsequent diagnostic, therapeutic and patient education decisions.  The personal values of the dyad enter into the discussion frequently as do other contextual phenomena, such as life, family , education and work considerations.  One contextual element frequently encountered is the migration narrative or movement of the patient.  Where are they going?  What is next in their life, work or play?

How does their migration impact the differential diagnosis and the plan and follow-up?

What does the patient believe about their condition and the plan to address it?  Sometimes I'm surprised by the patient's activity on the agreed to plan.  Someone with a serious heart condition may stop a medication that keeps them out of emergency rooms and end up in an emergency room.  At the follow-up to the emergency visit, I want to determine where their heart is in its degeneration and consider dosage adjustment of medication or addition of other medications until it comes up that they stopped the medication.  "I thought that might be the cause of my indigestion" "I wasn't sleeping well and I thought the medicine might be part of my insomnia."

As we share better with each other, especially as we share the development of the differential diagnosis, it becomes easier to seek clarification about how and when to use the medication.  And when to share information with their Family Physician.

The Differential Diagnosis is one of the anchors of medical care.  It keeps us focused and engaged.

More later.

1 comment:

  1. Wish all FP pphysicians were as thorough instead of ordering so many tests. mas