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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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Oliver is a 14-year-old boy who presents with a chief concern of left dorsal midfoot pain. According to Oliver, the pain began more than a month ago. Oliver's mother is present to assist with giving the history. Oliver's primary concern is that kicking a soccer ball is particularly painful. The patient does not recall any particular incident 1 month ago. However, he does remember falling on his left leg during soccer about 6 months ago. Now his foot hurts with every step he takes, but it is better when he sits at school. The mother reports that Oliver "has always had flat feet" and she believes that is why he is currently having pain.

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Oliver is healthy and does not take any medications. He is in the ninth grade at school and "likes it OK." No one in his family has similar problems. He has an older brother and a younger sister, both of whom have met normal developmental milestones without health issues.

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Oliver is reticent in his responses to your questions. He is a little overweight. Gait observation as he walked into the interview revealed that he walks with his feet slightly externally rotated with a mild left antalgic gait pattern.

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Steps

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

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  • Left foot pain distal to the malleoli

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STEP #2: Identify barriers to communication.

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  • Fourteen-year-old male patient and its associated issues with communication. History gathering from a child patient requires sensitivity to age-appropriate language and understanding of the body.

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Teaching Comments:

The involvement of the child in health care consultations ...

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