Clinical methods

The diagnostic process

Dr. Khaled D. Al-Harby

MBBS, ABFM, SBFM
Consultant Family Physician

Dr. Khaled Dhaifullah

Inductive and hypotheticodeductive
methods of problem-solving
• Inductive method: full history + full
examination + investigation = diagnosis
• In reality, most clinicians reach diagnosis
by a process of hypotheticodeductive
reasoning, i.e. by educated guessing and
testing .
• HD method enables doctors to solve
problems with maximum time- and cost-
effectiveness and minimal disturbance to
patients Dr. Khaled Dhaifullah
 Some practical tips to assist in
generating diagnosis
• Make use of the stage of PDI
• Clarify the presenting symptoms or the pivotal
symptoms
• Diverse symptoms and signs are commonly caused
by a single disease or entity
• Remember:
- uncommon manifestations of common conditions
are more common than common manifestations of
uncommon conditions
- Simple conditions are caused by simple problems
• Use checklists to trigger your memory, 5 : 2 ratio
(most likely: less likely butDhaifullah
Dr. Khaled important to consider)
 Checklists
Surgical sieve
• Congenital
• Acquired:
Traumatic
Infective
Inflammatory
Metabolic
Hematological
Degenerative
Psychological
Iatrogenic
Dr. Khaled Dhaifullah
 Checklists
systemic approach
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Neurological
• Hemopoietic
Dr. Khaled Dhaifullah
 Checklists
anatomic approach
• Skin
• Muscle
• Bones
• Pleura
• Lungs
• Heart
• Esophagus \ stomach
Dr. Khaled Dhaifullah
 Relative contribution of H\O, P\E,
Investigations in the diagnostic process.
• In medical OPD:
• history alone determine the diagnosis in 56
% of all referral made (27-56%)
• Physical examination : 17 % (0-24%)
• Routine investigation: 5% (0-17%)
• Special investigations: 18% (6-58%)
• Routine CBC & urinalysis: 1%
Dr. Khaled Dhaifullah
Generating and ranking appropriate
diagnostic possibilities
• Probability: (the most likely)
• Seriousness: (the average GP is likely to
encounter a malignant melanoma only once or
twice in a professional lifetime, so suspicion
should be genius.
• Treatability: hypothyroidism is an uncommon
cause of tiredness but it should not be overlooked
as it is readily corrected by replacement therapy
• Novelty: e.g pheochromocytoma as a cause of
hypertension
Dr. Khaled Dhaifullah
 Common errors in diagnostic
process
• Unwarranted fixation on a hypothesis:
twisting all data in an attempt to fit it)
• Premature closure of hypothesis generation
• Rule-out syndrome: (due to poorly focused
history-taking)
• Generation of very unlikely hypothesis
(novelty)

Dr. Khaled Dhaifullah

 The triple diagnosis
• In generating diagnostic hypothesis, it is also
essential to think in physical, social, and
psychological terms (as appropriate)
• Example: acne vulgaris in a teenage girl:
- physical: dermatological problem
- Social: social withdrawal due to poor self- image
and self- confidence
- Psychological: trauma (which may lead to
anxiety and depression)
Dr. Khaled Dhaifullah
 Use of time as a diagnostic aid

• Wait and see approach

• About 72 % of patients who had originally been
undiagnosed did not need to return to their doctor
mainly because of spontaneous remission of
symptoms
• The doctor must be able to control in himself and
in his patient the almost inevitable feelings of
uncertainty
• Use safety net properly
• It allows doctor to have a course between the
„over-reaction‟ andDr.the
Khaled“under-reaction”
Dhaifullah
By using time as a deliberate diagnostic
strategy in appropriate circumstances, the
doctor can avoid the following problems:
• Devoting too much time to minor or self-limiting
conditions
• Unnecessarily subjecting his patients to
inconvenient, painful or costly investigations
• Increasing his patient‟s anxiety
• Referring to other specialties too frequently or
with an inappropriate degree of urgency

Dr. Khaled Dhaifullah