How Physicians Make a Diagnosis

About 15 years ago, one of my former patient, who was taking Premedical courses joined me in my practice to observe and follow me. I treated her like a “medical student.” I demonstrated to her how to take history and do physical examination. After about two months she was able to diagnosed common pediatric problems such as ear infection, sinusitis, asthma, pneumonia, viral infection, gastroenteritis, etc.

When my son, Len, finished premed at the University of Maine twelve years ago, he joined my practice. He observed how I get a clinical history, do physical examination, and request for laboratory tests. He also learned how to make diagnosis and order some laboratory tests and X-ray.

With these two experiences, I realized that to make a diagnosis is not difficult. Now that the Internet is overflowing with medical web sites, anyone with time and interest could help their physicians make a diagnosis. Non-physicians could make a fairly close diagnosis if they know the process how physicians do it because of the availability of medical information in the Internet.

Starting today,  I will start this section on “how to help your clinician” get to your problem efficiently. I believe that if you know the process on how clinicians make a diagnosis, you will be able to communicate with him or her effectively and maybe even reduce medical errors and the cost of health care.

The diagnostic process starts with the Chief Complaint. This is the main reason why you brought your child to your clinician.

The common Chief Complaint in children are: fever, cough, runny nose, rashes, belly pain, hyperactivity, headache, etc.

From the Chief Complaint, a clinician automatically make a Differential Diagnosis in their mind. They mentally list about 3 to 7 different conditions that could explain the Chief Complaint. And from these list, a clinician would ask questions to rule in or rule out one or two of the Differential Diagnosis.

This line of questioning form the Present Illness component of the Clinical History. A good Present Illness history usually will lead to the right diagnosis.

Example: You brought your child to your clinician because of cough. (The Chief Compliant).

The usual first question that many clinicians will ask is: “Is there a fever?” If there is no fever with the cough, the next question is: “How long is the cough going on?” If the cough is longer than 2 to 3 weeks, many clinicians will ask: “Is there coughing after running, playing, or crying?”

With this scenario, coughing for 3 weeks without a fever and precipitated after running, playing, or laughing, a clinician will put asthma on top of the Differential Diagnosis.

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Leo Leonidas, MD, FAAP

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