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CHAPTER 2 Transparent diagnosis
32
Differences of opinion about a diagnosis
Differences of opinion can sometimes cause consternation; a common
reaction is that someone has to be wrong. Different opinions can all be
valid if they are based on documented experience and framed as prob-
ability statements with a sensible element of doubt. For example, if a
physician makes a number of different predictions with 50% certainty and
50% turn out to be correct overall, this shows good overall judgment.
Different members of the team can thus hold different valid opinions
about a diagnosis for a particular patient on the basis of their different
personal experiences. A doctor may be wrong about a prediction for a
particular patient and yet be correct 75% of the time for such predictions
with a 75% probability when they are all taken together in the long run.
However, if a single opinion has to be adopted by a team to decide
what should be done for a particular patient, then traditionally the opin-
ion of the most senior member present is adopted (usually after this
person has listened carefully to others).
If an opinion is totally certain, then it implies that all other opinions
must be wrong. An opinion held with certainty also raises questions
about the holder’s judgment because, in the long run, it is unlikely that
100% of predictions will be correct. An opinion may become distorted
consciously or subconsciously because the holder stands to gain person-
ally from its implementation. It is therefore important to be able to reas-
sure patients and team members if there are differences of opinion.
It is also important not to confuse opinions about outcomes with rules
that a team has agreed to abide by. A team member may point out that a
rule should be followed; this is not an overconfident opinion but a fact, if
it was agreed at a particular time and place. Overconfidence is also dif-
ferent from decisiveness. One can be decisive by choosing an option with
a low probability of success because it represents the best of a number
of poor options.
Differences of opinion may occur because the particular facts on which
they are based are different. The first thing to do when there is a differ-
ence of opinion, therefore, is to check the particular facts for the patient
and, if necessary, review the methods and conventions used by the team
to get agreement. This process may allow facts to be replicated (see
Transparency and Replication, p. 30).
The second thing to do is to clarify the personal and published experi-
ence on which the opinion and probability are based. This would include
the facts that identified the group of patients who were followed and the
details of outcomes, such as the diagnostic criteria used or the treatment
results.
Clarification of the facts often leads to agreement by revealing over-
sights and misunderstandings or pooling of experience. Meta-analysis is a
technique for combining data from different publications. Bayesian statis-
ticians also combine documented data with personal, undocumented,
subjective experience. Decision analysis can be used to ask patients’
opinions of how they would feel about different outcomes, so that this
can be taken into account when interpreting the meta-analyses and the
personal experiences of doctors.
DIFFERENCES OF OPINION ABOUT A DIAGNOSIS1
33
Many opinions are straightforward, and failure to hold some of them
might be considered culpable (e.g., that bacterial meningitis should always
be treated with antibiotics). There are also particular schools of thought,
and these are often represented by local guidelines (e.g., which antibiotic
should be used as first-line treatment). If teams agree to abide by such
guidelines, then differences of opinion are minimized and teamwork is
made easier.
Clinical audit is designed to detect poor performance that might be
due to poor choice of guidelines for diagnosis or for treatment. How-
ever, there is less formal scientific evidence in the literature to guide us in
choosing between diagnostic criteria than between treatments. As in
other Oxford Handbooks, the blank spaces in this book are there for you
to express your own opinions.
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Chapter 3
35
History-taking skills
and imagination
History taking with imagination 36
The case history: an example 38
The past medical history 39
The drug history 40
Diagnostic significance of the drug history 40
The family history 41
The social history 41
The review of systems 42
NAD 46
The preliminary diagnosis 47
Medical diagnostic sieves 48
Surgical diagnostic sieves 48
Management sieves 49
Use a plan for writing out the history 50
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CHAPTER 3 History-taking skills and imagination
36
History taking with imagination
The aim of the diagnostic process is to build an imaginative picture of what
is happening to the patient. Diagnosis is derived from the Greek “to see
through” (i.e., the history, physical examination, special investigations, and
response to treatment).
The diagnosis must not imply that there is only some single hidden
process that needs to be discovered. The diagnosis (or diagnostic formula-
tion) may have to include various causes, consequences, interactions, and
other independent processes. As well as internal medical processes, it
has to include external factors such as circumstances at home and the
effects on self-care, employment, and leisure.
Clearly, the most informative part of this broad diagnostic process will
be the history. The history also enables patients and supporters to iden-
tify the issues that they want addressed in terms of discomfort, loss of
function, and difficulties with day-to-day existence. Gold standards for final
diagnoses are best based on the outcome of patients’ symptoms combined
with the result of histology, biochemistry, or some other measurements.
So, final diagnoses are often based on initial history-taking skills from which
outcomes can be assessed.
Observe normal social conventions. Introduce yourself politely and
invite the patient and any accompanying persons to do the same. Check
details such as the patient’s date of birth, address, etc.
It is then important to establish very clearly why the patient has sought
help. This is known as the chief (or presenting) complaint. Ask the patient
about its severity and duration and always record this. Be prepared to act
immediately to give symptomatic relief (e.g., for pain) if the patient is
distressed.
In some cases, the chief complaint may not explain the decision to seek
help. The patient may be too ill, shy, guilty, or embarrassed to describe
what is happening accurately. In other cases, it may be someone else who
is unduly worried (e.g., the wife of a lethargic husband, parents of a child
or caregivers of an elderly person who can no longer cope). Be alert and
explore the real reason if there is doubt.
Having established the chief complaint(s), establish the factual details of
place and time. It is the ability to give a place and time that establishes
the complaints as facts. (Medicine shares this convention with pure science
and law.)
Listen to what the patient says without prompting first, but, if neces-
sary, ask where they were and what they were doing when the problem
was first noticed. This will help the patient to recall what happened and
also stimulate your own diagnostic imagination.
Establish the speed of initial onset and subsequent change in severity
with time. This helps you to imagine the kind of pathological process that
is taking place. An onset within seconds suggests a fit or heart rhythm
abnormality; over minutes, a bleed or clotting process; hours to days, an
acute infection; days to weeks, a chronic infection; weeks to months, a
tumor; and months to years, a degenerative process.
HISTORY TAKING WITH IMAGINATION1
37
The site may be anatomical, e.g., abdominal pain, or systemic, e.g., a
cough. By convention, facts are details that include a time and place that
can be checked.
If there are other complaints, note the same details (the time courses
of other new symptoms are often the same, however). Ask about other
associated, aggravating, and relieving factors, especially as a result of the
patient’s own actions and those of others. Ask what the patient thinks is
going on.
You will have to continue with cycles of evidence, diagnosis, action,
more evidence, revised diagnoses, further action, etc. Establish not only
what the patient’s complaints are and document them, but also the
patient’s own fears and actions. This will be the starting point for your
own explanation and suggestions to the patient later about what is to be
done.
Write out your history in a systematic way, for example, as shown in
the next section. Go over it with the patient, if possible, to check that it
is right.
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CHAPTER 3 History-taking skills and imagination
38
The case history: an example
Ms. AM, age 31 (DOB: 2/28/77)
23 Smith Street, My Town
Emergency admission: October 16, 2005 at 7 p.m.
Chief complaint (CC): severe sore throat, sweats,
and severe malaise for 2 days
History of presenting illness (HPI): The patient was well until
last Thursday afternoon, October 14, when she developed a sore
throat at work as a secretary at an insurance company. It was relieved
that day by warm drinks and acetaminophen, but when she woke the
following morning it was very severe. It was no longer relieved by
acetaminophen (she found swallowing very painful) and she was too
unwell to get up. There had been no previous sore throats. She
thought that her neck was getting stiff. Her friend had died of menin-
gococcal meningitis a few years previously and this worried her. She
called her PCP and was seen at the clinic that day. The doctor was
concerned that she lived alone and looked very unwell and had her
admitted to the hospital.
The most striking symptom in this case is the severe sore throat that is
getting worse. This is an example of a feature with a short list of
causes—a good lead. Most readers will have experienced a sore throat
and be aware that it is usually due to a viral pharyngitis, tonsillitis (due to
a hemolytic streptococcus), glandular fever, or something else in a rela-
tively small proportion of cases (see p. 100). Very rarely, these causes
include the beginning of a meningococcal infection. This loomed large in
the patient’s mind because of the fate of her friend. The history is com-
patible with all of these possibilities.
If a better lead with an even shorter differential diagnosis turns up
later, you may use that. Use the other findings to try to confirm one
cause of the shortest lead (and thus eliminate the others). Consider if the
remaining abnormal findings could resolve if the confirmed diagnosis
were treated. If not, look for another coexisting diagnosis.
This handbook contains a selection of findings with short differential
diagnoses. Single and small combinations of findings of this kind form the
foundation of the process of arriving at a working diagnosis (i.e., until the
diagnosis is final and no further tests or treatment changes are contem-
plated). With growing experience, you will learn to recognize more
combinations that usually point to a single or a few diagnoses and have to
resort less often to working through the possibilities in a conscious way,
using the concepts described in this book.
However, you will continue to be faced with new or strange situations
throughout your career; this is what makes medical practice such a chal-
lenge. The approaches you develop early in your career to deal with new
situations will stand you in good stead for the remainder of your career.
The next step is the past medical history (PMH).
THE PAST MEDICAL HISTORY1
39
The past medical history
PMH: Thyrotoxicosis discovered 6 months ago. (Anxiety, weight loss,
abnormal thyroid function tests in Osler Hospital.) Taking carbimazole,
5 mg daily.
The past medical history (PMH) in this case has three components: the
diagnosis, the evidence, and the management. Thyrotoxicosis is the diag-
nosis, which summarizes what is imagined to have happened. Anxiety,
weight loss, and abnormal thyroid function tests summarize the evidence
for imaging what had happened. The management was taking carbima-
zole, 5 mg daily.
In many cases, the patient would not be able to provide these details
and they would have to be extracted from the hospital or primary care
records, in which case it is helpful to name the hospital (the fictitious
Osler Hospital, in this case) or primary care center or doctor responsible.
It is important to note, however, that a comprehensive PMH in this
format can be written immediately after any consultation—in the hospital
or primary care center—with results and dates. It can be included with
any communication so that the recipient does not have to hunt for the
details. It is very helpful for those that follow the initial consultation (and
this may include you). From time to time in the hand-written follow-up
notes you may wish to take stock and write down a current PMH that
sets out the numbered list of diagnoses, with the evidence and management
in parentheses.
In this case, the past history also raises the possibility of recurrence of
thyroid disease causing the sore throat, but the only thyroid condition that
would do this is acute thyroiditis (viral or autoimmune). This is a rare
condition and is not included in lists of common causes of a sore throat.
The message to be taken away from this example is that if the patient
has had a condition in the PMH, possible links should be recalled or
looked up to see if any of these could explain the presenting problem. In
this sense, a history of chronic or recurrent conditions can be used as a
lead. So, any type of lead with a short list of possible associations should
be considered.
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CHAPTER 3 History-taking skills and imagination
40
The drug history
The drug history (DH) is often placed at the very end of the history,
before the examination findings; it is a matter of personal choice. How-
ever, if the patient is on medication, then it indicates that there is an
active medical condition, not just a past medical history. Therefore, there
is something to be said for documenting the drug history immediately
after the past medical history so that past and current conditions can be
considered together.
Drug history: Acetaminophen 1 g q6hr (for ? viral pharyngitis: sore
throat for 2 days with fever, and general malaise) with carbimazole
5 mg daily for thyrotoxicosis (see PMH for evidence)
- Alcohol 10 units per week
- Nonsmoker
- No other recreational drugs
Diagnostic significance of the
drug history
Note that the indication for acetaminophen is given in the form of one
possible diagnosis (other differentials could have been included) and the
evidence for the diagnosis. This is good practice (not often followed).
The evidence for thyrotoxicosis has been given already in the past medical
history. Recreational drugs have also been covered in this drug history,
but they are often included with the social history.
If you look up the side effects of carbimazole, you will see that they
include agranulocytosis, which could explain the sore throat. If this was
known when the HPI was being written out, it could be included as a
possible causal factor in the HPI.
Risk factors for future or current illnesses (such as smoking) can exist
in the drug history, past medical history, family history (e.g., of diabetes),
or social history.
THE SOCIAL HISTORY1
41
The family history
FH:
Father aged 56 Hypertension
Mother aged 55 Diabetes (onset at 50)
Siblings male: Age 34—alive and well
Age 26—alive and well
female: Age 30—alive and well
Children—none
The family history (FH) rarely contains features that form powerful leads.
In general, there will be risk factors in the family history. For example,
the fact that the patient’s mother had type 2 diabetes means that there is
an increased risk of the patient developing type 2 diabetes mellitus. This
may have no immediate bearing on the current problems (but she should
be checked for diabetes if only to exclude its presence so far). The patient
could nonetheless be advised to adopt a healthy diet and lifestyle.
The social history
The social history (SH) is always relevant. The activities of daily living can
be considered under the heading of domestic, work, and leisure. Imagine
what any person has to do from waking up in the morning to going to
sleep at night and consider whether the patient needs support with any
of these activities.
Fit, young adults who are expected to recover completely may miss
school, college, or work, and the timing of their return will have to be
considered. Patients who are more dependent on others such as children
and the elderly may need special provisions. Patients with permanent
disabilities may need help with most if not all activities of daily living.
SH: Alone in an apartment at present (roommate on vacation for
another week)
Parents live 200 miles away
Works as secretary for insurance firm
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