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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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You receive a phone call from a good friend of yours who is a graduate student at the University of Southern California. Her son has mentioned that he has pain in his right hip. Your friend is unsure of exactly where the pain is. She's hoping that you will check out her child to see if an expensive journey through the medical system can be avoided.

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Billy is 7 years old and is a good student in the second grade. Questions directed to your friend indicate that Billy's pain came on gradually about 2 months ago, a few days after he fell off his bicycle. He is a healthy boy overall and has had all of his immunizations. She admits that he has had several intermittent low-grade fevers, but there have been a lot of "bugs" going around his school. Billy has a 5-year-old sister who is developing typically.

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You agree to see him. Billy walks into the clinic with a right antalgic gait pattern. When asked, Billy points vaguely to his right hip above the greater trochanter and in front of his upper thigh.

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Steps

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STEP #1: Identify the patient's chief concern.

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  • Right anterolateral hip pain

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STEP #2: Identify barriers to communication.

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  • This is a personal referral from a friend.

  • Patient is a 7-year-old male, which suggests associated issues with communication.

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STEP #3: Identify special concerns.

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  • Family history. Though no details are known, the mother has identified a possible family history of a bleeding disorder.

  • Recent illness. This may raise the index of ...

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