Clinical Presentation Series: Forming a Differential Diagnosis
By: Dr. Nicole DeLauro, Director, ABPM
A healthy 30 year old male presents with right forefoot pain present for two weeks. The patient is an avid runner, and runs approximately 3 to 5 miles a day. He describes the pain as aching and throbbing. The pain continues throughout the day. He does have relief when resting. He has tried to abstain from running and admits to changing his shoes. He has had minimal improvement. He denies any other treatments.
What is your diagnosis?
As physicians we are forced to be investigators. We have to ask the correct questions regarding the complaint, form a diagnosis, and provide a treatment plan. To do this, we need to formulate a “differential diagnosis.”
The differential is a list of potential diagnoses compiled based on the complaint. It is important not only to determine the best treatment plan but also to treat patients in a timely fashion. The differential helps to narrow down more than one probable cause for the patient’s pain. Your differential can be based on the well known acronym, “NLDOCAT.” What is the nature and characteristic of the pain? Is it burning, shooting, aching, dull, etc? This helps you determine if it’s arthritic, neurological, vascular or musculoskeletal in nature. Once we know which system in involved, focus on the location. What structures are in the area? What nerves, tendons, ligaments, bones, and/or joints are located there? Does it radiate to any surrounding area? The duration of the pain helps decipher if it is an acute complaint secondary to potential trauma or chronic in nature. What makes the pain better or worse? Is it aggravated by activity or rest? Better in or out of shoes? Worse at the beginning or end of day? Does shoe gear alleviate or aggravate the pain? What treatments has the patient tried and has there been any improvement?
Once you have the answers to these questions, the differential is easy to devise. This methodical approach will help you avoid pitfalls and provide better care for your patients. Based on this approach, what differentials do you have in mind? You should be thinking about stress vs. occult fractures, bursitis, metatarsalgia, tendonitis, sprain, and even neuroma. The symptoms can also be aggravated by the patient’s foot type, biomechanical gait pattern, and even improper shoe gear. Further questioning, clinical examination, and diagnostic studies will help to lessen the amount of differentials and ultimately attain a definitive diagnosis.
As a young physician, you have the tools to alleviate complaints based on your final diagnosis and gain a patient’s trust and confidence in your care. Your patients will have done their own research before they walk through your door, and expect a certain quality of care. In order to constantly exceed these expectations, you must maintain the highest level of expertise and excellence within the profession. Having a methodological approach towards your evaluations, and being board qualified and/or certified upholds this level, and informs your patients that you have been tested and challenged extensively within your specialty. This message, when conveyed to patients will solidify their confidence in you as their physician and create a lasting doctor-patient relationship.