In medical school, we learn to approach patients with the following workflow
Chief Complaint(CC) --> History(Hx) --> Physica(PE) -->Differential Dx(DDx) --> Labs --> Imaging(Img) --> Treatment(Tx) --> Disposition(Dispo)
This works great if your patient is able to give a nice concise history. However, often times patients may have multiple complaints and may be disorganized with their history. This can lead the provider down a windy road and after 20 minutes the provider may not have a clear idea of what is going on.
To solve this problem it is important to move the DDx to after the CC. The DDx should focus on the critical diagnoses that cannot be missed. These are the potential high mortality diagnosis that could cause the chief complaint.
The new work flow should be
Reassessment of the DDx after the PE is important to prevent early anchoring. If the patient has a wildcard (i.e. Immunosuppressed) it is important to loop back and dig deeper in the Hx and PE. This process is repeated until an appropriate DDx is developed after which the labs, Img, and treatment can be ordered. For more information on Wild Cards check out our lecture on the subject (Wild Cards: Avoiding Land Mines)
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