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Note

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NOTE: This case demonstration was developed using the diagnostic process described in Chapter 4 and demonstrated in Chapter 5. The reader is encouraged to use this diagnostic process in order to ensure thorough clinical reasoning. If additional elaboration is required on the information presented in this chapter, please consult Chapters 4 and 5.

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THE DIAGNOSTIC PROCESS

  • Step 1 Identify the patient's chief concern.

  • Step 2 Identify barriers to communication.

  • Step 3 Identify special concerns.

  • Step 4 Create a symptom timeline and sketch the anatomy (if needed).

  • Step 5 Create a diagnostic hypothesis list considering all possible forms of remote and local pathology that could cause the patient's chief concern.

  • Step 6 Sort the diagnostic hypothesis list by epidemiology and specific case characteristics.

  • Step 7 Ask specific questions to rule specific conditions or pathological categories less likely.

  • Step 8 Re-sort the diagnostic hypothesis list based on the patient's responses to specific questioning.

  • Step 9 Perform tests to differentiate among the remaining diagnostic hypotheses.

  • Step 10 Re-sort the diagnostic hypothesis list based on the patient's responses to specific tests.

  • Step 11 Decide on a diagnostic impression.

  • Step 12 Determine the appropriate patient disposition.

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Case Description

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Mrs. RS is an 82-year-old retired teacher who lives alone in a single-story ranch-style home on a 3-acre property. She has been widowed for 10 years and has four grown children. Though unsure of the exact timeline, it seems that during the past 6 months, she has noted increasing difficulty standing up after sitting on a low couch, getting around her house, and pulling weeds in her garden nearby the house. She has a history of three falls in the past 6 months, none of which has been associated with serious injury. She presents to the session with her son who drove her and is in the waiting room. Mrs. RS does drive short distances from her home, maintains her own checking account, and attends two routine weekly functions with her friends. She has refused any assistive device and holds onto her son's arm as she enters the clinic.

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When asked why she was falling and having trouble getting around, Mrs. RS replied that her "legs don't work like they used to" and she rubs her thighs as she says this. She states she is slow to get up and get going in the morning as she feels that her "legs need to wake up," and she reports nonspecific intermittent "pains." If her son walks too fast, then she does sometimes get short of breath. She does wear glasses and saw an ophthalmologist this past year for a "routine checkup." She also wears one hearing aid while in "social settings." Mrs. RS states she is in "good health" and denies a personal history of cardiac disease, respiratory pathology, or cancer. She denies alcohol or recreational drug use and is a nonsmoker.

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