The Process of Diagnosis cleveland

Differential Diagnosis Dr. Michael Ramcharan Chiropractic Physician / Clinician / Instructor Cleveland Chiropractic College – KC Clinical Sciences Division GED734 - Lecture 1 1 Definition: Diagnosis A diagnosis is the determination of the nature of the disease, injury, or congenital defect (steadman’s medical dictionary 2000) The act or process of identifying or determining the nature and cause of a disease or injury through evaluation of patient history, examination, and review of laboratory data. (answer.com) GED734 - Lecture 1 2 Differential Diagnosis  Distinguishing between diseases of similar character by comparing their signs and symptoms (answer.com)  The process of weighing the probability of one disease versus that of other diseases possibly accounting for a patient's illness. The differential diagnosis of rhinitis (a runny nose) includes allergic rhinitis (hayfever), the abuse of nasal decongestants and, of course, the common cold, sinusitis. (medicine.net) GED734 - Lecture 1 3 The Process of Diagnosis  The essential purpose of diagnosis is to differentiate one disorder from another The purpose of diagnosis is to assist in determining the level (intervention) and type of care (management plan) to be provided to the patient Diagnosis is the link between the source data and the management plan and is the evidence that a clinical decision making process has been undertaken to determine the nature of the clinical problem GED734 - Lecture 1 4 Diagnostic Decision Making  Pattern recognition  Probability reasoning  Causal thinking  Hypothetico-deductive clinical decision making process GED734 - Lecture 1 5  Disease centered vs. Patient centered  Multiple levels of diagnosis      Possible diagnosis Probable diagnosis Working diagnosis Presumed diagnosis Definitive diagnosis GED734 - Lecture 1 6 Multiple Levels of Diagnosis  Possible diagnosis     The moment a pt enters the clinical environment, any dx is possible According to Murtagh, these are the “serious disorders that must not be missed” Severe infections, septicemia, infective endocarditis, or coronary disease, MI, unstable angia, arrythmias, which all generate pain patterns that mimic MSK pain Manual physician must also consider neoplasms, especially metastatic to and from the spine, CES, VBI as possible cofounders or dx GED734 - Lecture 1 7 Multiple Levels of Diagnosis  Probable Diagnosis     In manual healthcare, each general presentation has a group of probable diagnosis of MSK relevance Those which must not be missed and those which may masquerade to confuse the issue There is no substitute for a through H & P and spinal assessment of the pt for sorting through the probabilities The probable dx are from a list of possible dx, which are not excluded by the hx in the first instance, and then are further tested in the second GED734 - Lecture 1 8 Case  Probable Diagnosis    PPW generalized LBP w/ stiffness and radiating pain into one leg, ending approximately at the knee 5 probable MSK dx exist Probable MSK Dx are: GED734 - Lecture 1 9 Probable Diagnosis case  Lumbar disk protrusion w/ NR involvement  Facet syndrome (posterior jt dysfxn)  Subluxation complex w/in the L/S or Pelvis  SI joint syndrome  MFPS of the low back and pelvic musculature GED734 - Lecture 1 10  The exclusion of the probable dx by clinical assessment is a process which leads to the inclusion of the most probable dx which then becomes the working dx  If the assessment fails to provide convincing evidence of spinal dysfunction or other biomechanical dysfunction, with specific findings which explain the pain and the nature of the presenting complaint, then there is little, if any evidence for a dx suitable for manual healthcare and the pt should be referred for medical assessment GED734 - Lecture 1 11 Multiple Levels of Diagnosis  Working Diagnosis    A descriptive statement or series of statements which integrate the believed cause of the presentation with the many clinical elements which are manifested in various forms “Best guess of what's happening to the pt” Its not a problem to say that it’s the clinicians “best guess” as long as the process of reaching this point was exhaustive and documented, where as, if a guess was made within seconds of the pt entering the clinic, then there is reason for suspicion GED734 - Lecture 1 12  In manual healthcare, spinal dysfunction is largely a neurophysiological disorder manifested through functional changes as opposed to physical pathological changes  The working dx of somatic lesions or a subluxation complex is one which must be tested by the application of specific therapies  A positive response of the patient can be taking as suggesting the working dx had validity only when all other probable dx were excluded GED734 - Lecture 1 13 Multiple Levels of Diagnosis  Presumed Diagnosis   Manipulation of the spine is diagnostic and therapeutic A positive response to treatment can be seen as evidence that the problem intended to be treated by the treatment was most likely present and that the treatment adequately corrected the problem GED734 - Lecture 1 14  Manual physicians cannot be criticized for working at the level of presumed diagnosis as this is a common trait of all health disciplines, especially medicine GED734 - Lecture 1 15 Multiple Levels of Diagnosis  Definitive Diagnosis    Disorders and diseases which result in pathological changes can be evidenced on autopsy and represent the group of presumptive diagnoses which become definitive Spinal lesions are functional and their effects nonpathological in the sense that they do not result in known organic change These conditions are not evident on autopsy, although there may seem to be a range of objective findings such as, disk herniation and hypertropy of the facet joints, neither which are pathognomonic indicators of the VSC GED734 - Lecture 1 16  The very fact that the majority of lesions diagnosed and treated my manual physicians can only remain a presumed diagnosis at best is the reason why manual healthcare is an art as well as a science GED734 - Lecture 1 17 Writing a Diagnosis  Temporal dimension  Clinical entity  Causation  Associations  Effect  Suggestive of GED734 - Lecture 1 18 Temporal Dimension  Working diagnosis to commence with words which anchor the presentation in time  Appropriate terms include acute, subacute, chronic, recurrent and familiar  Convey a mental picture of how the patient is experiencing the problem  TD may be supplemented by a demographic statement to set the scene for the diagnostic statements which follow: GED734 - Lecture 1 19 TD  “a 35 YO female primary school teacher with recurrent..”  “A 55 YO male motor mechanic with chronic....” GED734 - Lecture 1 20 Clinical Entity  Broad diagnostic label which serves to position patients and their presentation within a context which is clearly appropriate to the provision of manual healthcare  Encapsulates the pt’s perception of the problem which thus links the pt into the diagnostic statements  These include neck pain, headaches, LBP, shoulder and arm pain and mid thoracic pain and discomfort. GED734 - Lecture 1 21 CE  Demonstrates how a powerful mental picture can be generated by careful use of appropriate words  “a 35 YO female primary school teacher with recurrent neck pain and headaches…”  “A 55 YO male motor mechanic with chronic mid thoracic pain and discomfort..” GED734 - Lecture 1 22 CE  Every pt must be individualized within the diagnostic statement  The working diagnosis is highly variable in its content and comprehensiveness GED734 - Lecture 1 23 Causation  Mechanism of injury or disorder  Inclusion of causation within the diagnostic statement helps to differentiate level types of care GED734 - Lecture 1 24 Causation  “a 35 YO female primary school teacher with recurrent neck pain and headaches of unknown origin…”  “A 55 YO male motor mechanic with chronic mid thoracic pain and discomfort which is known to be relieved by (adjustment) spinal manipulation…” GED734 - Lecture 1 25 Associations  The identification of associated findings is the essence of the working dx  MHCP are able to identify and categorize the clinical signs, symptoms, and findings of the spine as being the object of treatment  Findings are evidence for the spinal dysfunction and can be ordered as the elements of the FSL  Benefits of associated findings within the WD, form a clear clinical picture of a particular problem GED734 - Lecture 1 26 Associations       Kinematic changes Connective tissue changes Muscle changes Neural changes Vascular changes “a 35 YO female primary school teacher with recurrent neck pain and headaches of unknown origin associated with restricted intersegmental movement in the Upper cervical spine…” GED734 - Lecture 1 27 Effect  The WD may also include a statement of the effect on the pt of this particular problem  Quantitative in that it resulted in time off work or has affected other activities of daily living  Qualitative in that it may be impacting on the biopsychosocial dimensions of the pt’s existence or both  For example, chronic LBP is commonly associated with time off work, sexual dysfunction and depression GED734 - Lecture 1 28 Suggestive of  Statements culminate in the specific cause or working dx to address  An impression of what the findings most likely indicate  “ these findings are suggestive of …” GED734 - Lecture 1 29 Conclusion  Purpose of assessing the pt in general and the spine is to identify areas of dysfunction associated with the complaints of the pt with a view to informing the most appropriate management plan for those problems  Goal is restoration of optimal health for the individual pt  WD mini-narrative which is descriptive of the problem and its effects on the pt GED734 - Lecture 1 30  Powerful patient-centered documentation of the clinical encounter  The more complete the diagnostic statement, the more justifiable the treatment, and justifiable treatments lead to valid outcomes measurements which feed back to inform the healing journey further GED734 - Lecture 1 31 Case Presentations  Clinical Presentation       PPW or CC – 5 questions to ask pt possible dx History – probable dx Clinical findings and examination Lab and special imaging - working dx Intervention and treatment plan Lecture chiropractic E&M GED734 - Lecture 1 32 Clinical Case Applications  Differential Diagnosis (most probable to least: be specific)  Most probable: Working Diagnosis  Treatment (be specific as types, dosages, duration, frequency, etc.)  Medical management  Chiropractic management  Prognosis (be specific to this particular pt) GED734 - Lecture 1 33