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Not knowing the diagnosis of a patient’s complaint after a history and examination is undesirable, but does happen. Physicians are able to evaluate patients, their complaints, test results and arrive at the correct diagnosis and help in rapid order much more often than not.
This is not always the case.
This occurs in any profession where diagnosis of a problem is necessary. It is important, however, to refer for testing, a specialist, or for a second opinion based on differential diagnosis when the cause of symptoms can not be ascertained. It is also important when attempts at treatment have provided no benefit or the condition is worsening.
Differential diagnoses are what physicians are taught to come up with as possible causes for a patient’s problem or problems in addition to the primary diagnosis.
The differential diagnoses are important as a fall-back diagnosis to look in other directions for the cause of pain or disease if the obvious or primary diagnosis is incorrect.
Having differential diagnoses helps the doctor help the patient, as they serve as contingencies and time savers in getting to the root of the problem so the most appropriate treatment, test or referral can be made in a timely fashion.
A patient with heel pain may tell me they are convinced they have a heel spur based on what other people have told them. Many times they are correct in diagnosing plantar fascitis, but there are also times they are not — and treatment for plantar fascitis will not help.
Stress fracture of the heel, fat-pad atrophy, bone tumor or cyst, flexor tendonitis, lumbar radiculopathy, gout and bursitis are some of the other common causes of heel pain.
These are differential diagnoses that must be considered if treatment for heel spur or plantar fascitis fails or does not coincide with a patient’s history or physical examination.
Treatment for fascitis when the real problem is radiculopathy will always fail.
A red, hot, painful and swollen toe could be an ingrown toenail. Gout, trauma or ill-fitting shoes in a patient with neuropathy, peripheral artery disease or microembolization, cellulitis, osteomyelitis and lumbar radiculopathy could also be etiologies of red, hot, painful and swollen toes. Antibiotics will not help a gout attack.
Do not be afraid to ask what else could cause the symptoms you are experiencing.
I find this often helps me as the discussion with a patient often brings more clues to light in finding the cause of the problem, or helps solidify the diagnosis that has been made.
David B. Raynor. DPM, is a podiatrist in Inverness and can be reached at 352-726-3668 or at www.AdvancedAnkleAndFootCenters.com with questions or suggestions for future columns.