Jarrod Shapiro, DPM Practice Perfect Editor Mountain View Medical & Surgical Associates, Madras, Oregon

Diagnosis, Diagnosis, Diagnosis

Have you ever been stumped trying to make a patient’s diagnosis?  Many of us wouldn’t admit to it, but we’ve all been in the position of being unable to figure out a diagnosis on a patient. “How can we not know the diagnosis?”, some may argue.  We are the specialists, the experts in the foot and ankle.  Out loud we’ll come up with something, often telling our patients what we “suspect,” our differential.  We then have two choices.  One: stop, presume the diagnosis, and start treating the patient for the presumed diagnosis.  Two, admit we’re not sure and continue searching for the diagnosis. 

Now, many reading this may say, “I don’t miss diagnoses.  Shapiro’s crazy, and he’s a poor diagnostician.”  I would, of course, respectfully disagree on both counts (well, maybe not the crazy part).  I’ll argue my point with one simple word: neuroma.  I can’t even count anymore how many patients I’ve seen either referred from their primary care doctor or after seeing another podiatrist with an incorrect diagnosis of Morton’s neuroma.  Often the patient will already have undergone neurectomy without symptom resolution.  Very often the symptoms and physical examination will point to a lesser metatarsophalangeal joint derangement.  I’ll treat these folks with either an orthotic or surgery with significant improvement. I know I’m not the only doctor in history to have trouble making a diagnosis. If diagnosis was easy, then “failure to diagnose” wouldn’t be one of the top reasons physicians are sued. 

	Tonight's Lecture is Venous Thromboembolism presented by Alan Hamdan, MD.

Here’s another one.  I’ve seen nonhealing diabetic ulcerations with severe peripheral arterial disease that have been debrided by other physicians.  Clearly these other doctors either missed the PAD or (worse) didn’t know they shouldn’t debride an ulcer in a patient with PAD.  Again, no one’s perfect; the diagnosis is NOT always correctly made. 

Diagnose, Diagnose, Diagnose

With real estate, it’s location, location, location.  In medicine, it’s diagnose, diagnose, diagnose.  The key to successfully treating any disorder is to first obtain a correct diagnosis.  How can a physician rationally treat a patient’s problem without first knowing what that problem actually is?  Let’s take the simple example of a pedal rash.  Very often, when we see a rash on the plantar surface of the foot, we’ll leap to the diagnosis of tinea pedis.  Of course, if the correct diagnosis turns out to be irritant contact dermatitis, then the initial treatment with either topical or oral antifungals would be unsuccessful.  Diagnosis is the cornerstone of appropriate medical care.

Making the diagnosis, though, is not always cut and dried.  A common complaint I see in the office is dorsal midfoot pain.  I remember an obese female patient I saw recently complaining of pain at the dorsal 4th metatarsal base.  I tried multiple diagnostic modalities (radiographs, EMG/NCV, MRI, bone scan), as well as multiple follow-up visits, repeat injections, etc., never actually diagnosing this patient with anything more specific than metatarsalgia with overload symptoms from her weight and foot type (a very mild cavus).  I was finally successful with some padding and orthotic therapy. 

Making the Diagnosis

So how can we most successfully utilize making the correct diagnosis to help our patients?  Listed below are some thoughts to make the correct diagnosis.

1. Take the time.  It’s tempting to rush through a patient encounter, especially when the diagnosis seems clear.  Take a moment to realize that, although the diagnosis may seem clear, it is still possible to make a hasty incorrect diagnosis.  It’s also very possible to miss contributing factors to a correct diagnosis.  For example, diagnosis of a symptomatic pediatric flatfoot problem may be straightforward, but failure to appreciate rigidity or peroneal spasm will delay and inappropriately treat a tarsal coalition. 
2. Listen to your patients.  Remember, most diagnoses can be made simply by listening to your patient’s history.  At the very least, it’s possible to determine what system the patient’s complaint involves.   In a patient complaining of unilateral paresthesias on the plantar aspect of the foot, the pain is most likely neurological in origin (lumbosacral spinal disease, nerve entrapment in the leg, or tarsal tunnel syndrome, for instance).
3. Consider the anatomical approach.  When examining patients, think about the associated anatomy.  In a patient with lateral ankle pain, think about the specific anatomical components when palpating areas of pain.  Is the pain in the sinus tarsi, one of the ankle gutters, ATF ligament, CF ligament, PTF ligament, or one of the peroneal tendons?  Similarly, consider what anatomy is functioning during the provocative part of the exam.  Lateral ankle pain with resisted eversion may be indicative of peroneal tendonosis.
4. Use a systematic approach.  Perform your physical examination systematically, doing it the same each time.  This way, you’re less likely to miss areas of pathology.  This is also true for the entire patient encounter.  Skipping components of your history taking, for instance, may cause you to miss information that you may find important but your patient does not.  For example, failing to ask about recent changes to exercise routines or shoegear may lead a physician away from a stress fracture diagnosis.
5. Determine the differential.  In all cases, it is possible to create a list of differentials that, at the very least, should be considered if the patient does not respond to the doctor’s treatment plan.  A 40 year-old woman with forefoot pain that the doctor diagnoses as metatarsalgia secondary to hammertoes should also at least consider the possibility of rheumatoid arthritis (among others) as a differential. 
6. Utilize ancillary testing.  When appropriate, utilize other testing methods such as blood testing, advanced imaging, bone scanning, ultrasound, etc. A recent patient of mine had a painful 1st MTP joint and tibial sesamoid with questionable sesamoid axial xrays that turned out to have an elevated uric acid level with blood testing and a diagnosis of gout.  Keep in mind, though, ancillary testing is used to CONFIRM a diagnosis.  Remember to have that differential in mind when ordering the appropriate tests.  Nothing replaces a thorough history and physical!
7. Refer.  When all else fails (maybe even before then), consider a second opinion from either another podiatrist or other appropriate specialist.  You’re not a lesser physician if you refer your patients to someone else.  Sometimes a second set of eyes will help to clear up a confusing patient issue.

Hopefully these thoughts will be helpful the next time you have a difficult diagnosis.  One final note that may be helpful: documentation.  Remember to document your findings thoroughly and accurately.  This is helpful from a medicolegal standpoint, but it’s also beneficial to compare repeat encounter findings with prior notes that may help determine a diagnosis (and at least preventing the physician from repeating the same thing twice).  Consider also photographing clinical areas of interest which, along with documenting interval changes, may also allow you to “examine” the patient after they’ve already left.  Write in with your thoughts to assist with difficult diagnoses.  And remember, the cornerstone to successful treatment is to make the diagnosis.  Know what you’re treating. 

Keep writing in with your thoughts and comments or our eTalk discussion forum on PRESENT Podiatry and start or get in on the discussion. We'll see you next week. Best wishes!

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

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