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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

Maria is a 6-month-old girl whose parents noticed at 4 months of age that she held her head turned to the side and that her face seemed somewhat asymmetrical. Maria has two older siblings who are healthy and well.

Their pediatrician referred them to the local general outpatient orthopedic physical therapy practice for exercises for congenital muscular torticollis. Maria's mother states that she has been performing the home exercise program "faithfully every day" for 2 months and there has been no change. The pediatrician has not seen Maria since the appointment 2 months ago. The mother is coming to you, as a Pediatric Certified Specialist, for a second opinion.

Maria's family recently moved here from Mexico. Maria's parents speak some English, but are more comfortable speaking Spanish. You notice as Maria's mother holds her that Maria holds her head turned to the right with her neck tilted to the left.


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

  • The chief concern of Maria's parents is her asymmetrical head posture and facial features.

STEP #2: Identify barriers to communication.

  • Patient's/family's preferred language is different than that of the health care provider. Maria's parents are most comfortable speaking Spanish; therefore, an interpreter is necessary for the verbal part of the differential diagnosis process. It is important to ensure that the discriminating questions and answers are accurately translated for everyone.

  • Presence of other children in the family. Because the mother has had two children who are healthy and well, there is a level of experiential wisdom that also needs to ...

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