A better understanding of how
doctors make diagnoses can help the
consumer get the most out of a
doctor visit.
A better understanding of how
doctors make diagnoses can
help the consumer get the most
out of a doctor visit.
By no means am I suggesting that
patients need to know how to make a
diagnosis but rather that a better
understanding of the mechanics of
the process may help avoid
unnecessary waste of time and money
in trying to provide care.
Testing has a greater role in
preventive care where the goal is to
look for problems before symptoms
begin.
So what is a diagnosis? A diagnosis is
the final conclusion of all the facts in
the case. Pneumonia, appendicitis,
asthma are all examples of diagnoses.
This is the disease process that will be
treated.
There are many misconceptions
within the general public with regards
to how a doctor arrives at a diagnosis.
Ask most non medical consumers and
they will say that the diagnosis was
made by a test like a blood sample or
an imaging study like a CT scan. This
cannot be further from the truth. In
fact diagnostic testing in my opinion is
almost the least important part of
making a diagnosis.
I cringe when my colleagues order
tests before even examining the
patient. In my opinion this can be
misleading and adds unnecessary
cost and time to the patient often with
very little added information.
For example while on rounds earlier
today I was asked to see a patient that
was admitted with a fever. After a
brief interview and a physical
examination I concluded that she had
a pyelonephritis, an infection of her
kidney. I went on to tell her that I
planned to give her an antibiotic and
some fluids. She and her family then
asked if I was going to perform any
tests. When I replied that none were
further needed unless she did not
respond as expected, they were taken
aback. I explained that the clinical
history and physical examination was
clear enough to make the diagnosis in
this young otherwise healthy lady.
Appropriate treatment was started
and her fever did as predicted abate
and she felt better the following
morning. Later the following day she
was discharged feeling much better.
So how did I arrive at the diagnosis
without ordering any tests? The same
way doctors have done for hundreds
of years by using their knowledge of
medicine. When I was a medical
student my professor would say “Take
a detailed history the diagnosis will
come to you”.
So what is the first step in making a
diagnosis? The first step is to
understand the chief complaint . The
chief complaint is the main reason
the patient decided to come to the
doctor. “My side hurts” or “I have a
headache” are simple examples of a
chief complaint. Just this simple one
sentence with the age and sex of the
patient will narrow the diagnosis
considerably. My side hurts in a young
woman above would narrow the
diagnosis to an abdominal problem.
The next step is the history of the
complaint . When did it start? What
other features are present with it? Is it
getting better or worse? Is the patient
losing weight unexpectedly? Was
there any recent travel? Any fever?
Chills? Diarrhea? These may be some
of the other features that can
accompany the chief complaint “My
side hurts” This will further narrow
down the possibilities of the
diagnosis. In the above patient she
had a fever of 104F with chills and
shivering without any diarrhea.
Already we have been able to narrow
the diagnosis to most likely a kidney
infection. Unfortunately this is the part
that most busy physicians spend the
least amount of time with and often
patients are least willing to participate
in. I cannot tell you the number of
times I have been told by patients or
their family members to “Just look at
the tests that the other doc ordered”
or ”I have already told the ER doc all
this, why are you asking me this
again?” I always get a detailed history
on my own, like most other things in
life the devil is in the details.
Think about your symptoms not
about the diagnosis
Further information on past medical
problems, surgeries, pregnancies and
medications are now looked at.
By the time I have taken the history I
often am at least 80% certain of the
diagnosis. Now comes the physical
examination.
A physical examination is the part
where the doctor will methodically
examine every organ system of the
body for clues of the disease process
including the vital signs. Already
having a fair idea of the diagnosis the
astute physician can further
strengthen or refute the possibility of
a diagnosis. By the time I have
finished my physical examination I
can often by over 90% sure of the
diagnosis or have a very short list of
the possibilities.
Mind you we still have not ordered
any tests. In fact most medical school
training is spent to understand what is
normal and what is not. After all one
cannot be expected to recognize
something as abnormal if they do not
know what normal is. A very small
proportion of medical school training
is on actual “tests”.
Back to our case; on examination she
is shivering, appears dehydrated and
has a rapid pulse rate, all indicating
infection. Her abdomen is soft and
without tenderness. This was
important to exclude any other
abdominal diagnosis that would have
been a reasonable alternative
diagnosis. In fact she did have a
tender right flank that further added
the likelihood that she is suffering
from a kidney infection.
So without ordering a single test
I am over 90% certain
So without ordering a single test I am
over 90% certain that she has a right
sided kidney infection as a result of
which she is also dehydrated. She
should respond to antibiotics and
fluids. Which she did.
Her chief complaint was the flank pain
and her diagnosis was kidney
infection.
Does she need any further testing?
In this case not at this time.
Am I advocating no testing? Not at all.
A test is just that, a test. A challenge to
see which way to proceed. But one
must first have a destination. First
have a reasonable set of diagnosis
after a thorough history and physical
examination then order the test that
will be most helpful in breaking the
stale mate. That is the best use of
resources.
Most diagnosis can be made without
any tests, some even without even
touching the patient. Very often
misguided testing produces
unexpected inconsequential findings
that have nothing to do with the
original complaint which often leads
to more testing and so on.
The most notorious test that I
encounter in my day to day practice is
where a patient goes to his healthcare
provider with a fever and a throat
strep test is ordered without
examining the throat. This can be
positive even without strep throat.
Which unfortunately as soon as it is
positive the further search for the
diagnosis comes to a grinding halt.
Practitioners please do not swab non
inflamed throats!
So how does one get the most out
the doctors visit, but clearly stating the
reason for the visit, the complaint is a
very important reason for the visit. Do
not try to analyze and arrive at the
diagnosis yourself. Also be ready to
give the duration of the illness and
any other associated symptoms that
may go with it. All this will help make
an accurate diagnosis minimize
diagnostics and expedite treatment.
Remember be wary of the doctor who
orders tests before even asking what
the problem is.
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You guys that would go to quack lab scientists for medical tests and treatment.pls beware. medical diagnosis does not mean medical test and vice versa.

Patients do contribute to some of the problems.They think until they do a test,they have not been well checked out.Many are products of hearsay from neighbours.