How Fast Should You Come up with Your Differential Diagnosis?

[surfguy84]

We're getting a lot early experience with standardized patients at my school. The other day, we saw a patient complaining of upper GI pain. The physician assigned to oversee my H&P kept peppering me with questions about the differential. As an M1, I have a hard time coming up with relevant things on the spot. I'm sure if I had more time to think I could reason some other issues out.

My question is, in the real world (or even during M3/4), how long do you have to come up with a comprehensive differential? Do you literally have 10-15 seconds to list everything that might be the cause, or do you typically have longer and/or the ability to discuss it over amongst colleagues?

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[JustPlainBill]

Comes with time -- we were taught that by the time you were an MS3, you should have 5 of the most commons for each CC by the time you were walking into the exam room --

Example: CC: "Every time I eat pizza, I have this burning, nasty taste in my mouth" -- when the patient shows up as ready for provider you have from then until you get to the door to come up with the top 5 ---- and you should have some general questions in mind to cover each of the top 5 to help move it up/down the list.

 

[chizledfrmstone]

We're getting a lot early experience with standardized patients at my school. The other day, we saw a patient complaining of upper GI pain. The physician assigned to oversee my H&P kept peppering me with questions about the differential. As an M1, I have a hard time coming up with relevant things on the spot. I'm sure if I had more time to think I could reason some other issues out.

My question is, in the real world (or even during M3/4), how long do you have to come up with a comprehensive differential? Do you literally have 10-15 seconds to list everything that might be the cause, or do you typically have longer and/or the ability to discuss it over amongst colleagues?

If you could come up with a comprehensive DDx on the spot as a MS1 why would we need all those extra years of school??

They're pushing you to think harder and faster. Just keep working at it and practice.

 

[TheBoneDoctah]

I'm an MS0.5 and I come up with 10 DDx when I see the CC. I don't understand why you can't do this.

 

[Drrrrrr. Celty]

With upper GI pain you probably should be able to come up with a few ddx without any issue tbh. Peptic ulcer, duodenal ulcer, gastritis, gred, maybe pancreatis gallbladder issue, etc. Thats where you start going from a general idea to doing a few tests to comprehend whether or not your ddxs are realistic, i.e do a murphy test to check out if the gallbladder is the problem and or look for weird skin color changes. Maybe check gi sounds in case there's an obstruction, then for the plan order endoscopy or etc.

I mean the hard part is when you get a patient with a disorder that's clearly one you haven't covered before. Ex. one of my standardized patients probably had some sort of rhumetalogical issue and all I know how to test for is things like carpel tunnel and or nerve issues. So it was pretty much a case of well I'm going to touch where it hurts, but I have no clue whats the matter.

 

[Drrrrrr. Celty]

I'm an MS0.5 and I come up with 10 DDx when I see the CC. I don't understand why you can't do this.

I see that WebDO neural implant is treating you well.

 

[Goro]

That's easy...#1 should be the pepperonis!!

Sorry, couldn't resist! Kudos to Bill for allowing me to use him as my straight man!

Example: CC: "Every time I eat pizza, I have this burning, nasty taste in my mouth" -- when the patient shows up as ready for provider you have from then until you get to the door to come up with the top 5 ---- and you should have some general questions in mind to cover each of the top 5 to help move it up/down the list.

 

[dfib slim]

.

 

[JustPlainBill]

That's easy...#1 should be the pepperonis!!

Sorry, couldn't resist! Kudos to Bill for allowing me to use him as my straight man!

Just another service I offer, @Goro --- right up there with sarcasm....

True Story ---

One night my Dad woke up in the middle of the night with an unusual chest pain -- the men in my family are all stocky when they're young and tend towards fat when they a) stop PT or b) get older or c)both --

So mom gets concerned, even though he's only 34 but he's got a desk job and only needs to qualify PT wise once a year in his AFSC -- so off we go to base hospital.

After we get all checked in and behind the curtain, ER doc comes back and begins the H&P --- after asking all the pertinent questions, he gets around to asking what Dad had for dinner ----

"Two enchiladas, two tacos, rice and beans at the NCO club" ---

the next phrase was,"Get out of my ER, Sarge and go get some Pepto" ---

Hilarious ---

 

[Rekt]

Depends on how your school is set up. I'd be able to, only from prior knowledge, but we do mostly basic sciences first year. I imagine systems based might give you an edge as far as M1 differentials go, otherwise that's a pretty useless question for an M1.