How do you develop your DDx?

[Aclamity]

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I'm in family med right now (first rotation) and lots of people come in with pretty simple problems. After taking the history usually one or two Dx are screaming out at me, but I know that when I present to my attending I need to have a couple DDx to "reason through." I end up just going to epocrates for the Dx I just made and looking at their DDx for that condition.

Problem is I feel like I'm doing this all wrong, that I shouldn't be using resources to develop a DDx, but rather should be keeping my mind wide open and generating it all on my own. I'm afraid of becoming too reliant on apps and books and stuff, and then having it come back and bite me in the butt later. It's just that it's pretty tough when one diagnosis is the clear winner.

How do you all develop differentials when evaluating/presenting a patient? Would you consider epocrates and other resources to be a harmful "crutch" to your development as a doctor? Is this just a skill that develops over time?

 

[MrBeauregard]

I call it diagnosis bias and I suffer from it as well. I've found a useful trick is to use the VINDICATE (vascular, infectious, neoplastic, degenerative, idiopathic, congenital, autoimmune/allergic, traumatic, endocrine) mnemonic. This allows you to take a step back from your suspected diagnosis (even though the chief complaint of "sore throat" and the constellation of symptoms is so obvious nearly anyone could make the proper diagnosis) and come up with a DDx of 4 to 5. Just ask yourself, "what could make someone's throat hurt?" and go from there. Obviously developing a larger DDx is more difficult when the diagnosis is literally screaming at you and easier when the symptoms are vague, but I've found that even in those instances when my mind wants to focus on the easy diagnosis this helps to expand my assessment a bit.

Also I'm just two weeks into my FM clerkship as well, so I'm struggling to get over this just like you. Hopefully there are some other people who can give us advice about how to get past this. I suspect it comes with experience and increase knowledge as well.

 

[DrSnips]

Start generating the DDx just from the CC, before you even get into the history.

 

[mjl1717]

Another tibit:

Always consider the most common and the most lethal..(eg. acute pharyngitis versing retropharyngeal abscess or carcinoma.