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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.



  • 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.


Case Description


Sophie is a 6-year-old female who presents to your clinic with her mother, a current patient and friend of yours that you have been treating for a while. Sophie's mother is at the clinic for her usual appointment, but she also would like your quick advice about Sophie. Sophie's mother was unable to schedule an appointment with Sophie's pediatrician, so no physician referral is available for consultation. Sophie has not been playing outside and her teachers have told Sophie's mother that Sophie has preferred to stay inside at her desk at recess for the past 3 months. Your daughter, who is a classmate and friend of Sophie's, also has talked about the fact that Sophie has not been playing as much lately. Sophie's mother reports that Sophie has reported pain in her left knee and feeling tired. This keeps her from playing games outside with her friends. Sophie's mother thought a physical therapist's advice would be especially useful. Sophie's mother reports she cannot recall Sophie talking about specifically injuring her knee, but Sophie's mother knows that at Sophie's age falls are common on the playground.




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


• Left knee pain and fatigue that precludes usual play


STEP #2: Identify barriers to communication.


  • Informal referral. This route of referral often requires that rapid assessments be made without the routine documentation. The clinician should be careful to take the time necessary to be thorough and generate follow-up documentation for the patient and patient's family, clinic, and the pediatrician as needed. Legal issues also may exist given the request to evaluate this patient without physician ...

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