Differential Diagnosis: Keep it Broad

Differential Diagnosis:

Your differential diagnosis is key to ensuring that you can come up with the correct final diagnosis. If it’s not in your differential diagnosis it wont be in your final diagnosis.

It’s important to start with a broad differential diagnosis, and by gathering your HPI, doing a detailed physical exam, and completing your work up, ruling out those diagnoses as you go.

It could be as simple as stating that lungs are clear bilaterally, therefore ruling out asthma, or it could be as complex as stating the lumbar puncture done was unremarkable for any signs of low glucose, elevated WBC, meningitis.

Option 1 for Success:

I have seen many successful new providers create differential diagnoses within their MDM macro. This allows them to automatically recall a previously constructed list of differentials without having to re-create them on the spot. For example: chest pain. If in your Macro for chest pain you have “pulmonary embolism, pneumonia, empyema, aortic dissection, boerhaaves syndrome, pericarditis, myocarditis, ACS heart attack, esophageal spasm, reflux” etc, you will never have to re-create that list in your mind and it will always be right in front of you when you are trying to make decisions about your testing and care.

Although this is a great option, there is a possible downside.

Legal: If your differential includes everything except for the diagnosis, ie. the patient had an esophageal rupture that you failed to mention as a possibility, this could come back to hurt you. If you use this method it might make sense to delete your differential list before submitting and finalizing your note. Alternatively you might mention “differential includes but is not limited to: xyz”.

Option 2 for Success:

Make yourself a resource, either paper or electronic, that has each complaint listed in alphabetical order. Under each complaint write out your differential diagnosis. Example: Headache: SAH, Meningitis, Traumatic Brain injury, Dural Venous Sinus Thrombosis, Benign Idiopathic intracranial hypertension, Migraine, Vertebral Dissection, Pituitary Apoplexy etc.

Make sure your note matches the clinical picture:

Another comment regarding your final diagnosis: it is important that your entire note reflects your thought process. You do not want a note to state the patient had a “sudden onset worst of life headache”, but later state that you “do not think a CT is necessary to rule out SAH.” Of course, always tell the truth, however make sure your note properly reflects your suspicion for worrisome diagnosis, or lack there of. The reader should be able to come up with the same conclusion without wondering why certain things were done or not done based on what you had already written.