Friday, August 3, 2012

"What happens when the patient do not seem to have any clear diagnosis in the OSCE" by Dr Vin @

Firstly, do not "freak" out, stay centred, and do what you usually do in real life and that is, to work through the problem in a systematic way.  Do not get fallen into the trap that there has to be a definitive diagnosis.  Remember, in "real" General Practice, it is relatively common NOT to have a definitive diagnosis at the end of the consult.

Saying that, you still need to demonstrate to the examiners your thinking process, your list of possible diagnoses or at least the type problems that you are dealing with eg ?Autoimmune, infective, malignancy, endocrine, neurological, paraneoplastic syndrome etc. and depending on what your differentials are, demonstrate to the examiner your ability to investigate and manage appropriately.

Make sure you bear in mind the following when managing the diagnostic problem above.....
  • If in your list of differentials includes something pretty nasty like subarachnoid haemorrhage or a myocardial infarction, make sure you rule this out first even if it is unlikely.  These diagnoses are NOT forgiving and hence, require your most attention.
  • Generally, try to list your differentials in order from most likely to least likely and have at least a working or provisional diagnosis.
  • When investigating, aim for the least invasive first and then the more invasive if required.
  • When investigating, always ask yourself how will this affect my management and if the answer is that it does not affect what you do, then probably do not order it.  An example would be ordering a CT scan of the lower back on someone with a possible disc prolapse who is not keen on surgical treatment, has no red flag signs and is keen to give conservative management including physiotherapy a trial.

Anyone with other suggestions, please feel free to contribute on our comment section.

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