Improving on Diagnosing

Discussion in 'Medical Students - DO' started by ohmanwaddup, Feb 11, 2019.

  1. ohmanwaddup

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    I feel like I'm struggling a lot with my SPs. I'm an MS1 and we have SPs about once or twice a block and while I usually feel like I obtain all the necessary information during the encounter, actually writing the SOAP note in a concise manner with good flow, and putting that information together to create a differential diagnosis is something I struggle with immensely. Does anyone have any good tips or resources to get better at this?
     
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  2. ciestar

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    Practice. Im a third year and still find this hard.
     
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  3. AlbinoHawk DO

    AlbinoHawk DO PeeGeeWai Osteopath
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    There are differential diagnosis apps out there for most common complains. You could make a flashcard deck about them and eventually you'll recall them faster. Of course, this is a first step and later in your training you'll unconsciously build on it
     
  4. Black Coffee 24/7

    Black Coffee 24/7 Probationary Status

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    It will become much easier during your clinical rotations in which you will be drilled on bread and butter top 3-5 differentials for common complaints.

    But, just keep practicing at it. Everyone struggles through it initially.
     
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  5. libertyyne

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    No m1 is doing a great job about generating differentials. If you are learning the class material well, you will start having broader diffrentials. and eventually with practice be able to narrow it down and exclude some zebras. At this point you should be thinking about the most common diagnosis associated with the CC, and presentations that are very stereotypical will be provided, so build cases for those.
     
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    #5 libertyyne, Feb 11, 2019
    Last edited: Feb 11, 2019
  6. Gurby

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    If you don't have a differential diagnosis in mind, how do you know that you have "obtained all the necessary information during the encounter"?

    I never bought into the whole OPQRST / OLDCARTS / whatever thing... What I do is listen to the complaint (ie. chest pain) and then mentally list out all the things that could conceivably be causing these symptoms. Each question I ask is something that should theoretically contribute to ruling some condition in or out, or move them up/down the list in terms of likeliness. Basically you should have a list of possible diagnoses within 30 seconds of saying "Hi my name is ohmanwaddup".... you shouldn't be trying to formulate it later.

    Your differential diagnosis should guide the interaction, not the other way around. It's like you're doing it backwards by blindly collecting information about "onset, location, duration, etc" and THEN thinking about differential after the fact.

    Just my 2 cents as an M2. Maybe this will bite me in the behind some day, but doing it this way feels more natural and more efficient to me.
     
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  7. FistLength

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    Definitely didn't know squat as an M1/M2, had no clue what to include on the differential, it gets better with time and practice. As an intern I use dynamed (has a DDx section), pocketbook, and learning from others.
     
  8. austintr

    austintr 5000 candles in the wind
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    One thing I'll add is just get used to sorting information. It sounds cryptic, but I find it really helpful to ask myself with every sign or symptom, "is this important/relevant/etc or not?"

    Then you'll get to the point where you can basically put different signs and symptoms into different mental buckets and ask "what could be causing this?"

    This will help you fill out a decent differential list for SPs first and second year. If your school is anything like mine, the SP cases will all be very straightforward and almost everything will fit with a specific diagnosis. The point is to get you used to thinking this way and work on tuning up your skills in history taking and physical exam before you get to clinical years so that you look at least 1% less dumb. The point should not be to stump you and give you complex cases that get you stuck every step of the way.
     
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  9. BorntobeDO?

    BorntobeDO? SDN Bronze Donor
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    Man you got to break down your basic pains-
    Belly pain? Is it RUQ- gallbladder, RLQ - appendix, LUQ - spleen/trauma/stomach, LLQ - diverticulitis
    Chest pain - Gerd vs MI
    Back pain - always some dumb stuff like muscle strain vs herniated disc vs clauda equina symptom (always)
    Arm pain - OMM
    shoulder pain - Thoracic outlet vs rotator cuff injury
    knee pain - acl vs mcl vs OMM nonsense
    Back pain that moves- kidney stones
    back pain that stabs - AAA


    I feel like thats 90% of OSCES right there.
     
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  10. alprazoslam

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    Flash cards listing each thing on ddx. For most common complaints
     
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  11. Neopolymath

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    The previous posters have really given great advice. I will say that a lot of people find the idea of differential diagnosis difficult because all of your cases and standardized patients have such a cookie cutter diagnosis (to help teach/reinforce the actual disease process and not really how to think) that you don't actually learn a lot about true differential diagnosis thinking. Coming up with DDx 3-5 on the list is hard when the person clearly has xyz in the basic scenario. I think you really start to learn when you know the pathology/symptoms and then have cases consisting of common issues presenting in uncommon ways. That's where it starts becoming a tangible tool in my opinion. I am an accomplished mechanic and have been using this style of thinking for a long time and had a bit of trouble at the beginning creating an extensive list because the cases were not a mystery. School provided cases just aren't as good as real life.

    Also, your school has to teach you some of this stuff because it is really to get you ready for Level 2 PE and not how you would do things in real life.
     
  12. Deecee2DO

    Deecee2DO Medical Student
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    Honestly, it will just take time. Im only an M1 but former practicing chiropractor. I practiced in multidisciplinary practices before med school and it took me ~3 years into chiro training to really feel comfortable with DDx/Hx taking/PE and in practice was still working on things. When I started seeing a lot of patients one after another in practice is when it started to feel more natural. I am still working on it as an M1 and nowhere near where I want to be as the differentials in medical practice far surpass that of what a chiro will see (strictly MSK dx). You'll be continuing to sharpen these skills well into practice as a physician. Eventually, you will start to feel more confident in your critical thinking process where your mind just heads in the right direction subconsciously. Initially youre like how the hell can I simultaneously exude confidence, converse with a patient, develop rapport, eye contact/writing balance, know which questions to ask starting with broad down to descriptive all while developing a DDx in my head, but with time, you'll just start to know which questions to ask and which questions are irrelevant etc. and it will all flow. You don't need to worry were all in the same boat bud thats why its called "practicing" medicine. Download Figure1 its a great app you can practice your Dx skills 24/7 on your phone
     
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    #12 Deecee2DO, Feb 12, 2019
    Last edited: Feb 13, 2019
  13. Steve_Zissou

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    That app is awesome! Thank you!
     
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  14. fldoctorgirl

    fldoctorgirl MS1 transplanted from the beach to the midwest
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    Not sure if it helps, but you're not alone. I feel the same way...for our SPs, it feels like I'm just memorizing differential dx's based off of the OSCE rather than actually thinking of them on my own. I think we just have to trust the process, even though it sucks to feel so clueless sometimes
     
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  15. Sardonix

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    That's cuz you are.

    OSCEs are nothing like actual medicine. When we did oral reports for OSCEs in order to get full points you basically had to bombard the preceptor with word-salad level of verbal content. Doing even a fraction of that during FM/EM/Surg rotations and my attending would cut me off and ask me to tone it down. IM is the only thing somewhat comparable, but even then it's a lot more relaxed and human than the robotic, points gaming BS that OSCEs are.
     
  16. NecrotizingFasciitis

    NecrotizingFasciitis SDN Bronze Donor
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    Kind of going off of this topic (feeling as if we're just memorizing OSCEs encounter to encounter, test to test), I spoke with fellows at my school b/c I was worried remembering all of the ridiculous setup minutia in OSCEs in OS (specifically counterstain when we first started) in the real world (ya know, if you're ever required to do it on a rotation or whatever) & was told "after you get through the first two years, you'll never have to memorize this crap again. Counterstrain is literally based off of what the patient feels. You aren't going to follow an OSCE, you're going to move them around until they feel better."

    After that conversation I felt a lot more relaxed about school in general. Cram FSTRA for the test, celebrate w/ a drink(s) afterwards, forget FSTRA, but carry the concept with you 'cause that's all that really matters.

    Kinda applies to a lot of the hardcore science stuff they teach us in school too; carry the concept you learned with you & refresh the nitty gritty as needed.
     
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    #16 NecrotizingFasciitis, Feb 14, 2019
    Last edited: Feb 14, 2019

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