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If you get anxious
or nervous easily when reading about possibility of
serious illnesses in your child, please not click on
the conditions below. There are lists of serious
conditions that can make you nervous.
Belly Pain Air Leaks From Lungs Acute Crying Back Pain Bed Wetting Big Lymph Node Big Spleen Blood in Urine Chronic Diarrhea Chest Pain Cough Coughing Up Blood Chronic Cough by Age Constipation Droopy Eye Ear Ache Enlarged Glands Eye Swelling Excessive Thrist Facial Paralysis Fainting Spell Feeding Problem GI Bleeding Headache Head Tilt Hives High ESR Hoarseness Joint Pain Limp Leg Pain Muscle Weakness Noisy Breathing Nose Bleeding Nose Obstruction Pain on Urination Pyuria Recurrent Infection Red Green Urine Ringing in the Ears Scrotal Swelling Seizures Stiff Neck Swelling of the Parotic Gland Toe Walking Toeing In Toeing Out Unequal Pupils Vomiting Vomiting of Blood Wheezing
Why Have a Complete Differential Diagnosis?
There are three components in making a diagnosis. These are Clinical History, Physical Examination, and Laboratory tests and Imaging. Among these three, the Clinical History is the most important one. Depending on the specialty of a physician, the History probably provide 80 to 90% of the diagnosis. Except in Dermatology, the Physical examination contribute only 10 to 15% to the diagnosis. Laboratory tests and Imaging is needed only in about 5 to 10% in making a diagnosis.
A good Clinical History is dependent on a complete and practical Differential Diagnosis. Without a reasonable and complete differential diagnosis, it is difficult to ask good questions, both pertinent positive and negative ones. The History starts with a Chief Complaint, then a clinician generates the pertinent questions that will reduce the number of considerations from the complete Differential diagnosis. Each question should be designed in such a way that will rule in or out one or two disease conditions that will result to the Chief Complaint.
Example: A three year old boy came because of wheezing. With wheezing as the main symptom that brought the parent to bring their child, a clinician who is not using any hand held computer or not hooked to the Internet, will search his or her memory during the interview. Most clinicians are capable only of mentally listing 6 to 7 different causes of wheezing. It might look like this: asthma, pneumonia, allergy, bronchitis, foreign body, cystic fibrosis, and bronchomalacia.
With this mental list, a clinician will ask questions such as: Is there a fever? How long has the wheezing going on? Is your child coughing after running? How long is he coughing? Is there a previous history of bronchitis or pneumonia? Is there chronic diarrhea? Is there family history of asthma or cystic fibrosis? When the coughing or wheezing started, did the child choke on a food or small toy? Is your child taking any inhaler? Is there asthma in the family?
Because the differential diagnosis is limited to seven conditions, the clinician runs out of pertinent questions to ask.
Now let us see a clinician with access to technology. Upon hearing the chief complaint, “Wheezing” he or she will get a PDA, hand held computer or Log on the Internet, and type “Wheezing” at a search box on Differential Diagnosis. The Modern Clinician with few strokes on the keyboard or tapping on the screen, can easily bring up a listing of at least 35 causes of “Wheezing” in children. From this electronic list, a clinician can easily pick the causes that are serious and more common. With such a list pertinent questions can be easily generated. Compared to the clinician who just relies on brute brain power, there is a fat chance that a not so common cause of wheezing, such as vascular ring or heart disease, can be easily missed during the first clinical encounter and diagnostic error may be the outcome.
In the coming few years, a list of differential diagnosis will include the pertinent questions to ask as well as diagnostic tests or imaging to order for a particular condition. It will be linked to a website with the latest Evidenced Medicine Management.
With the use of effective technology diagnostic errors will be reduced.
Table of Contents, Top of the Page
I wrote and desinged this website for parents of our practice. Before you use ideas from this website, please discuss it first with your clinician if you are not with our practice.
Leo Leonidas, MD, FAAP
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