Differential Diagnosis Generation
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Differential Diagnosis Generation

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"How I learned to stop worrying and love the BALM:" a method to developing a differential diagnosis

"How I learned to stop worrying and love the BALM:" a method to developing a differential diagnosis

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  • Examples: headache/CP/SOB. D-dimer, nitrazine test, amylase
  • Heuristics

Differential Diagnosis Generation Differential Diagnosis Generation Presentation Transcript

  • Differential Diagnosis
    Or “How I learned to stop worrying and love the BALM”
    Clinton Pong
  • Objectives
    Define “differential diagnosis”
    Errors
    aka how do you get the “right ddx”
    Develop a systematic, routine method for differential diagnosis generation
    The BALM
  • The Challenge: What is a Ddx?
    Recognize a collection of signs and symptoms
    Recall basic pathophysiology
    Restate in terms of disease
    Reconnect with the initial complaint
    Framing: pre-/post-test probability
    Reframing: Reconsidering ddx when there is a progression of unusual natural history
  • How many times have you done this?
    Premature closure of diagnosis
    “Hm, this is the cardio unit and they have chest pain. Duh. It’s a heart attack.”
    The crazy “House” diagnosis
    “Chest pain and shortness of breath?!? They could have a worm like Strongyloidesstercoralis that went up their gut into their lungs and then to their bloodstream!”
    The LI of the MINDNUMBING table of differentials A-Z + 1,2,3,4,5,6,7,8,9,10…
  • Cognitive Diagnostic Errors
    Examples:
    “Umm… trauma or cancer?”
    “80 years old? I thought you said 18 years old.”
    “Psh. It’s just a little ____.”
    “The ___ is (+) so it is ____.”
    “The __ is (-) so it is not __.”
    “It’s gotta be a ____.”
    Errors
    Faulty hypothesis generation
    Faulty context formulation
    Faulty information gathering/processing
    Inaccurate assessment of prevalence or severity
    Wrong interpretation of test
    Overrreliance on clinical axiom
    Faulty verification
    Premature closure of diagnosis
    “No-fault” errors
  • Many diagnostic errors occur because we try
    to fit the data to our hypothesis rather than
    fitting the hypothesis to our data.
    http://www.flickr.com/photos/epublicist/
  • http://hlwiki.slais.ubc.ca/index.php?title=Long_tail#Impact_in_medicine
    http://www.medrants.com/?p=3629
  • House, MD. White board
    http://differentialdiagnosi.proboards.com/index.cgi?
  • Occam’s Razor:Quest for the Holy Parsimony
    “Plurality should not be posited without necessity.”
    Pluralitas non estponenda sine necessitate
    http://en.wikipedia.org/wiki/William_of_Ockham
  • Sherlock Holmes
    "When you have eliminated the impossible, whatever remains, however improbable, must be the truth."
  • DeGowin’s Quotable:
    Disease is a four-dimensional story, which follows the biologic imperatives of its particular pathophysiology in specific anatomic sites as influenced by the unique characteristics of this patient.
    Your task is not verbal, but cinematic; construct a pathophysiologic and anatomic movie of the onset and progression of the illness: the words are generated from the images, not the images from the words.
  • Nobody ever needs to know that the instant you see lawyer [on the USMLE] you immediately think:
    “Scumbag who sleeps with prostitutes and therefore has gonorrhea, syphilis, chlamydia, and herpes.”
    It’ll stay our dirty little secret.
    http://www.agraphia.net/zac-fact-10-bigot-your-way-to-success/
  • Race/Ethnicity
    African Americans have sarcoid and sickle cell.White kids have cystic fibrosis and can’t dance.Japanese people have stomach cancer and ninja skills.
    Lifestyles
    Women are always pregnant. No matter how careful they were.Coke Addicts had an MI (don’t smoke crack, kids!)Patients with a swollen knee are female, young, hot, and caught gonorrhea from their last boyfriend.
    Etc…
    http://www.agraphia.net/zac-fact-10-bigot-your-way-to-success/
  • The BALM
    By systems
    Acute vs Chronic
    Local vs Systemic
    MEDICINE DOC
    Great tier system for starting off your ddx
    Where is it?
    Will it kill the patient?
    What else can it do?
    If all else fails, go to the laundry list.
  • Framework
    AcutevsChronic
    LocalvsSystemic
    High Probability – Incidence
    (the most difficult part of the frame as a medical student)
    What is most likely? Rare  Common
    High Utility – Morbidity/Mortality
    What do you want to make sure you never miss? Benign  Serious
  • The Systems Approach
    MEDICINE
    Metabolic/Medications
    Endocrine
    Degenerative
    Infection/Ischemia/Infarction
    Congenital
    Iatrogenic/Idiopathic
    Neoplastic
    Electrical (Neuro/Psych)
    Alternatively,
    • I VINDICATE AID
    • DIRECTION
    • VITAMIN C,D
    PE organ systems list
    Neuro
    Lung
    CV
    GI
    Renal/GU/GYN
    Heme/ID
    Endo
  • The Systems Approach
    VITAMIN C, D & E
    Vascular
    Infection/Ischemia/Infarction
    Trauma/Toxin
    Autoimmune
    Metabolic/Medications
    Iatrogenic/Idiopathic
    Neoplastic
    Congenital
    Degenerative
    Electrical (Neuro/Psych)
    Alternatively,
    • I VINDICATE AID
    • DIRECTION
    • MEDICINE
    PE organ systems list
    Neuro
    Lung
    CV
    GI
    Renal/GU/GYN
    Heme/ID
    Endo
  • By discipline
    Hint hint…
  • Resources
    Groopman, Jerome. How Doctors Think. Mariner Books © 2008.
    Kassirer, Jerome. Learning Clinical Reasoning. Williams and Wilkins. © 1991.
    DeGowin's Diagnostic Examination, Ninth Edition (Paperback) by Richard LeBlond (Author), Donald Brown (Author), Richard DeGowin (Author)
    http://en.wikipedia.org/wiki/William_of_Ockham
    (Heuristics) Bigot your way to Success on the USMLE
    http://www.agraphia.net/zac-fact-10-bigot-your-way-to-success/
    “Separating clinicians from automatons: the long tail”
    http://doctorrw.blogspot.com/2008/08/separating-clinicians-from-automatons.html