Diagnosis: Difference between revisions
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== Diagnostic Clinical Reasoning == | == Diagnostic Clinical Reasoning == | ||
[[Dual Process Theory]] is a key theory in the study of [[:Category:Clinical Reasoning|clinical reasoning]]. | |||
[[Dual Process Theory]] is a key theory in the study of | |||
'''System 1''' | '''System 1''' |
Revision as of 09:18, 27 April 2022
“In the fight which we have to wage incessantly against ignorance and quackery among the masses and follies of all sorts among the classes, diagnosis, not drugging, is our chief weapon of offence. Lack of systematic personal training in the methods of the recognition of disease leads to the misapplication of remedies, to long courses of treatment when treatment is useless, and so directly to that lack of confidence in our methods which is apt to place us in the eyes of the public on a level with empirics and quacks”
—William Osler 1904
Annemarie Jutel, medical sociologist at Victoria Unversity writes that "With few exceptions only the medical profession has the power to diagnose disease...Being able to diagnose is at the base of the social authority afford the doctor. It sets the doctor apart from the lay person and from other professionals, confirming the doctorās greater knowledge and status"
There are some other professions in New Zealand who are afforded the status of being able to diagnose within their fields - physiotherapy, osteopathy, chiropractic, midwifery, nurse practitioners, pharmacy prescribers. There has also recently been the provision for self-diagnosis of COVID-19 through RAT testing.
Abbreviated History
Galen 129-216
Galen was a prodigy having written three books by the age of 13. He was reported to have been incredibly arrogant. He did anatomical studies on animals, some correct but many incorrect deductions. For example he described the rete mirabilis of the brain of a calf and assigned it to a vital physiological role in humans - but it doesn't exist in humans. He made incorrect deductions about the circulatory system. However he made correct deductions about spinal injuries and devised that the brain not the heart was in charge of the body.
Galenism became holy writ, and later part of Church dogma. He championed blood letting (laudable pus) and used the theory of opposites called Contraria Contrariis. A famous quote from the time is "Christ as a second and neglected Galen.ā
Critics of āGalenās grand planā risked severe penalties. The grand plan was one that only he could recognise, and so after his death progress in medicine essentially stopped for 1,500 years.
Vesalius 1514-1564
Vesalius broke the dogma of Galenism. He studied anatomy through human dissections (previously disallowed). The human body rediscovered. He published a highly influential work called De Humani Corporis Fabrica Libri Septum.
He drew what he saw, not what Galen told him to see, but also made some errors. For example he hadn't fathomed the mechanism of circulation, he placed the lens in the centre of the eyeball, believed the vena cava came from the liver, and thought there only to be 7 cranial nerves.
Through Vesalius the anatomical view of body developed. This was the foundation of modern medicine. Others followed suit.
Sydenham 1624-1689
Sydenham brought about the classification of disease. He was committed to naming disease to enable communication between doctors and between doctors and students. The IASP Taxonomy can be traced back to this idea.
“All diseases then ought to be reducād to certain and determinate kinds, with the same exactness as we see it done by botanic writers in their treatises of plants”
—Sydenham
Morgagni 1682-1771
Morgagni founded the idea of patho-anatomical correlation through a publication of >500 autopsies in his book the sites and causes of disease in 1761. He compared diseased organs with normal ones and linked symptoms to abnormalities in the body. He made classic descriptions of angina, myocardial infarction, subacute bacterial endocarditis, strokes (lesion of cerebral blood vessels), hemiplegia due to a lesion on the opposite hemisphere of the brain.
Through morgagni we got the idea that physical diseases have physical causes, often in specific organs and tissues. The humoral theory was demolished.
Paris and German Schools of Medicine
“In 19th [the] centuryā¦symptoms [became] a window into otherwise hidden diseaseā¦ no longer [were they] individual phenomena, [but the] external expression of disease”
—Annemarie Jutel
Through the Paris school we had physical examination (including percussion and mediate auscultation), psychological assessment, and autopsies became routine for clinico-pathological correlation.
In the German school we had the likes of Virchow who propounded the cellular theory pathology and Koch.
Medical Humanism Model
William Osler (1849 ā 1919)
“The good physician treats the disease, the great physician treats the patient that has the disease”
—William Osler
The medical humanism model uses the reductionist biomedical approach as a base, but it is complemented by medical humanism. Humanism refers to the humanities rather than pyschological science. The model pays attention to the wishes, beliefs, fears of the patient. It is different to the Biopsychosocial model which is derived from psychoanalysis.
Biopsychosocial Model
Engel developed this influential model in the 70s derived from Psychoanalysis. It avoids biological reductionism and views all spheres as equally important. It has been criticized as being anti-humanistic and using psychological ideologies masquerading as science. It implies that the psychosocial is always relevant leading to stigma even in the face of evidence that a particular problem is rooted in a biomedical cause. This is contrasted to the medical humanism model where a humanistic approach is always relevant.
Physiological Diagnosis
In Musculoskeletal Medicine an important paradigm that developed was the idea of physiological diagnosis. This is captured by Bogdukās Postulates ā for diagnosing pain generators
Conflicts
There were huge debates in late 18th and 19th centuries. One group said it didnāt matter, just classify and treat. Another group (the etiologists) said it did matter. The etiologists mostly won this debate but there are still some clinicians who follow the "anti-reductionism" ideology. For example the ideology of classifying almost all chronic low back pain as "non-specific chronic low back pain" (despite copious evidence that most chronic low back pain has a biomedical source) is not a new ideology by any means, and is a vestige of the debates from 200-300 years ago. The different ideologies and how they all believe themselves to be "evidence based" is discussed further in Low Back Pain Treatment Strategies.
What is Knowledge?
The field of epistemology
Approximately =
Justified ā diagnosis needs to be based on something real
True ā pathophysiologically it has to be true
Belief ā I have to believe it to be true
What is Diagnosis?
There is a difference between science and medicine. The doctor's epistemic task is to figure out how to help or cure
“Diagnosis is not knowledge for knowledgeās sake. It is knowledge for the sake of action. Medicine exists to cure, to care, to intervene, or in limiting cases, to know when not to intervene. Medicine is not a contemplative science”
—Mainetti 1992
It is important to remember that taxonomy is a social creation. For example dyslexia is not a disease in a non-literate society. To be a disease it needs to be visible, problematic, and perceived to be related to medicine. It is a cultural expression of what is accepted as normal (e.g. drapetomania). Consider such diagnoses as AIDS, depression, infertility, ADHD, alcohol use disorder, obesity, and fibromyalgia.
It is a classification tool by allowing segmentation and organisation. There are three types of diagnoses.
- Patho-anatomical diagnoses (e.g. internal disc disruption)
- Symptomatic diagnoses (e.g. non-specific chronic low back pain)
- Medical unexplained symptoms (e.g. chronic primary pain)
The Benefits and Harms of Diagnosis
Benefits
“Diagnosis is both rudder and anchor”
—Annemarie Jutel
Rudder ā the pursuit of diagnosis guides the individual to the doctor
Anchor ā assignment of diagnosis positions identity and behaviour.
Annemarie Jutel
Personal diagnostic value to the patient
- Psychic value: patient given an explanation, clarifies, access to sick role
- Planning value: on patient life decisions e.g. work, retirement, financial plans, etc (prognosis
- Collective identity
Intrinsic diagnostic value to the broader system
- Research and Education value: More easily group with other similar patients to study the entity and develop treatments, CPD, quality outcomes
- Tool for political engagement and advocacy.
- Resource allocation: Which specialty should assume responsibility, access to physiotherapy, medications, prostheses, disability parking, WINZ, ACC, etc.
Impact on the doctor and doctor-patient decision making
- Knowledge Access: Allows the doctor to more effectively draw from their knowledge, do a literature review, or ask colleagues.
- Positive Therapeutic Utility: whether leads to improved outcome
- Negative Therapeutic Utility: whether prevents misadventure through inappropriate treatment, avoiding the harms associated with diagnostic error
The Value of the Explanation
Patients want a narrative for their pain. Delegitimisation is an experience or a series of negative consequences from not being seen to not being heard, to a sense of deficiency, and shame.
Patients have various expectations around diagnosis. Information needs are centred around a desire for a definitive diagnosis. Patients expect diagnosis through comprehensive physical examination and imaging. Accurate diagnoses are wanted for proving that their pain is real. Patients are not satisfied by āage-related wear and tearā explanations. Diagnostic satisfaction linked in with expectations of receiving a good physical examination.[1][2]
“It is a psychological fact that if you tell a patient that you do not know what is the matter with themā he wrote, āhe will immediately begin worrying. He will probably think that he has got some rare and awful disease, and will certainly think that you donāt know your job.ā He advocated āLatinizingā symptoms to give a ādiagnosis of sorts.ā āTo put into dog Latin the symptoms of which patient complains is not scientific, but it satisfies him every time . . . .”
—Sykes 1927
If tests confirm patient experience - Rhodes
ā[T]hey ran some tests and that's when they realized my whole spinal column was kitty catty womper. I felt relieved. I felt like, well, here's proof. It's not just me going crazy or complaining. It's black and white and anybody can see it. [The doctor] showed me and... he showed me where it hurt. He said, your disc is kinda bulging out there, just kinda laying on this nerve.ā
Q. So it sounds like you're happy with the diagnosis.
A. Yeah, I don't question it one bit. [All] anybody with a grain of sense would have to do is be shown the X-rays and it's right there, right in front of `em.
Intense Satisfaction with Diagnosis
I'm sure he thought that there was something wrong with the spine but nothing really serious. And they had done a CT scan which had turned up nothing. And they had done a normal X-ray which turned up nothing... And he kept telling me, we're just not finding anything. And I said, well, you can't hurt this bad and there not be something wrong... So finally, I think because I was insistent about it, he decided to do a myelogram... and I was laying on the table... and the technician said `Oh my gosh!' and I knew he had found it. And he called one of the doctors in.
āIt was wonderful... he showed me on the X-ray the nerves that were pinchedā
Collective Identity
Research and Education Value
Goitre Belt pre 1920s, 26-70% of children
Diagnosis in the 1944-1945 āHunger Winterā
Schizophrenia in the 1960s and 1970s
1960s Psychologically oriented approach ā due to harmful emotional experiences in childhood with primary caretakers (usually mothers)
1970s biological approach ā genetic susceptibility, biological alterations present, twin studies showed family environment was irrelevant, no statistically significant psychosocial traumas
Psychoanalysts were proven wrong. The reductionist approach was more humane than the psychosocial approach.
Superior Semicircular Canal Dehiscence
Discovered in 1998
Seen on very small slice CT
Symptoms = pressure or sound induced vertigo, bone conduction hyperacusis, and pulsatile tinnitus
Previous to 1998 these patients were biopsychosocial
Harms
There are various potential harms of diagnosis
- Denial of insurance
- Denial of employment: e.g. military etc
- Negative internal appraisal: ?Lead to regard oneself as forever flawed and unable to ārise aboveā ones problem (hypothesis)
- External stigma: e.g. EDS, endometriosis, CFS, alcohol use disorder, depression, borderline personality disorder
- Commercial exploitation: Fertile ground for exploitation of patients and doctors (e.g. āsocial phobiaā for shyness, endorses the use of medication)
- Marginalises unstudied populations (e.g. is endometriosis really more common in Pakeha women? Or are Pakeha women just more likely to seek care?)
Psychiatry Explains the Unexplainable
History of Hysteria
Multiple Sclerosis
Discovered in 1968 by Jean-Martin Charcot
Very challenging diagnosis
Diagnosis made easier by increased access to neurologists in the mid 20th century and then by MRI
Misdiagnosis as hysteria and neurosyphilis was common.
Hysteria and MS
āThe diagnosis [of multiple sclerosis] from hysteria is of the greatest importance, and it is often very difficult and sometimes impossible.ā
- Charles E. Beevor (1898)
āthe frequent mistaking of this condition [MS] for hysteria . . . in this condition [MS] we make many mistakes. . . . [I] was often forced to revise [the] diagnosis of hysteria.The characteristic striking remissions after very grave symptoms are misleadingā
- Dr Crafts, AMA (1917)
Diagnosis of hysteria reduced in mid 20th centuries with increased correct recognition of MS, but some diagnoses were changed to āepilepsyā āpsychosesā āFreudian psychoneurosesā
Recognition of MS allowed treatments to be developed
Initially hypnotism, psychological framework
1951 ā cortisone, effectively treated relapses but no long term effect
Currently more than 20 medications available for various types of MS
We have fancy new wastebasket terms for Hysteria
Previously
Wandering uterus
Hysteria
Sexual Frustration
Anxiety neuroses
Oedipus complex
Somatisation
Now
Medically unexplained symptoms
Central sensitisation
Somatic symptom disorder
Chronic primary pain
Conversion disorder
Biopsychosocial
Sociopsychobiomedical
Current Ideology in Medicine - Jutel
The prevalent assumption = if current technology canāt find the cause then it must be psychosomatic.
Medically unexplained is subsumed within psychiatry and used synonymously
The symptoms are āunjustified behavioursā
Based on assumptions linked to psychosomatic disorders
A psychiatric diagnosis implies that the patient might have the ability to control and reverse the symptoms
Leads to stigma and shame and encourages patient resistance
Current Ideology in Medicine
The psychiatric explanation relies on diagnosis by exclusion
It is a wastebasket diagnosis
This fails to acknowledge the limitations of knowledge
Presumes the infallibility of medicine
Shifts responsibility for cause and cure in a way that ignores sociohistorical realities
Current Ideology in Medicine - Jutel
Medically unexplained becomes ONE UNITARY LABEL
āthere is a pervasive reference to them as an entity, or as a unified condition that could be considered under one lightā ā Jutel
The problem of medically unexplained symptoms
The diagnosis of medically unexplained symptoms
The treatment of medically unexplained symptoms
Assumption = all complaints without explanation can be viewed in the same way
āThe greater the ignorance the greater the dogmatismā - Osler
All one treatment (intensive programme or day programme)
To me the ideology has a very alternative medicine flavour to it. E.g. everything treated with manipulation in vitalistic chiropractic
Also a quasi-religious flavour e.g. come back when youāve accepted the pain as your lord as saviour.
Some are so deep in this ideology that there is an outright denial of a biomedical cause even when it is staring at them in the face.
Patient reactions to no diagnosis (Dumit, Nettleton, Malterud, ā¦ā¦)
Increased dissatisfaction.
Increased distress
Patients blame their healthcare provider for their inability to explain the cause of their pain
Feel that their pain isnāt legitimate and disconfirmed
Back pain is invisible, no diagnosis leads those close to them to question the legitimacy of their complaints.
Fear of being stigmatised by a psychogenic explanation
Patient reactions to no diagnosis
āI told my doctor once that I felt like, my back hurt so bad I felt like I had a large grapefruit down about the curve of the back... Course there's not a grapefruit there and they X-rayed me and there's nothing there.ā
``The doctors... left me with the impression [my pain] was not realāā
`Even though a psychologically minded physician may try to reassure the patient that he or she is not suggesting that `your pain is imaginary'... the patient will very likely see the physician as suggesting just that''
If pain is not `in' the body, where can it be but in the mind?
Back to the Intrinsic Value of Diagnosis
1998 study Mushlin et al
68 individuals had diagnostic workup for suspected MS
59/62 felt better off having received diagnostic information
Definitive diagnosis made: less anxious and expressed favourable feelings about the diagnostic workup even though they faced a lifelong chronic disease
No definitive diagnosis made: more anxious and less reassured by the ānegativeā workup
Restitution Narrative a Cultural Problem?
Patientās expect:
I have pain ->
doctor will do imaging ->
source and cause of pain will be found through imaging ->
I will receive biomechanical treatment targeted at the source and cause ->
I will get better
There is a gross mismatch between patients information needs and clinician knowledge. (Lim, Hoffmann)
Psychosocial benefits from imaging - Lim
Despite strong desire for imaging to reach an accurate diagnosis
There are no measurable psychological benefits
The Contested Diagnosis (Dumit 2006)
The effect of diagnosing fibromyalgia (Jutel)
Initially a relief because it
validates their illness
provides reassurance
Provides credibility
But not uniformly welcome
Often felt need to keep a secret
Sense of stigmatisation because some health care professionals are quickly disinterested
Most āFibromyalgiaā is not āFibromyalgiaā
Wallit et al 2016 study of patients diagnosed as Fibromyalgia
73.5% did not meet the 2011 diagnostic criteria
Female = false positive OR of 8.81
Married = false positive OR of 3.27
White = false positive OR of 1.96
All three of white, married, female = true positive OR of 2.1
āThe diagnosis of fibromyalgia is frequently applied to those with milder somatic complaintsā
āOur data suggest that the term fibromyalgia has no clear valid or reliable clinical meaning or understanding, and is socially constructedā
āThe term best reflects persons for whom fibromyalgia has become part of their health narrativeā
Chronic Fatigue Syndrome (Deale and Wesely 2001)
2/3 felt they received an inappropriate psychiatric diagnosis
Patients believe strongly that their symptoms are due to a physical illness
Many doctors believe in the psychological origin
Biopsychosocial framework is not patient centred by being biased to the psychological
The model is contested by patient advocacy groups
Application of BPS leads to feelings of symptoms being trivialised
Model = initial viral illness, then symptoms perpetuated by dysfunctional illness beliefs and sickness behaviours.
Evidence for BPS model is lacking in terms of both validity and treatment approach
Applying the BPS model can cause harm
Psychology of Low Back Pain (Bogduk 2006)
No evidence that psychosocial factors are the cause of pain
Psychosocial findings are a perfectly reasonable consequence to persistent pain
Somatisation (pre-occupation) reflects that they feel they have pain
Depression is a natural consequence of any disabling disease that mercilessly persists
Hostility is provoked by doctors telling them there is nothing wrong
Obsessive compulsive traits because of dwelling on the pain that doesnāt remit
Psychotocism because they feel isolated in their suffering
Frustration because success is persistently thwarted
Uncertainty
Difference between non-diagnosis and uncertainty
10 minute episode of chest pain. Full work up for cardiac factors all clear. Non-diagnosis applied non-cardiac chest pain, sufficient
Vs. 6 months of recurrent daily chest pain, full work up gastro and cardiac all clear. Diagnostic uncertainty āmedically unexplainedā
Diagnostic Uncertainty
Aleotoric Uncertainty
Chance uncertainty
Disease variability
Disease incidence
Outcome variability
Epistemic Uncertainty
Limitations in knowledge
Doctors ability to access
Doctors ability to process
Translating population findings to individuals
Complex or poorly understood evidence
Three questions if a diagnosis canāt be made (Dhaliwal)
1.Have I reached the limit of my knowledge but not that of my colleagues?
2.Have I reached the limits of my local networkās knowledge but not that of another physician or team elsewhere?
3.Have I reached the limits of medical knowledge entirely (i.e., there is no known answer to the problem)?
Diagnostic Uncertainty
Open question = at what point do you āstopā and call it idiopathic?
Or at what point do you call it āpsychosocialā or as some call it āsociopsychobiomedicalā
Often ACC will decide when to stop.
What do you do?
Apply āwe donāt knowā āthat part of the manual of the human body hasnāt been written yetā
Apply a psychosomatic label?
Apply the āfunctionalā label?
Diagnostic Clinical Reasoning
Dual Process Theory is a key theory in the study of clinical reasoning.
System 1
- Reflexive, intuitive
- Efficient
- Pattern recognition
- E.g. 45 year old woman with a BMI of 40 with medial knee pain = knee OA
- Can lead to anchoring bias
System 2
- Analytical, cognitive
- Time intensive, deliberate
- Conscious, explicit application of analytical approach
- E.g. assessing the location of the lesion in foot drop.
- Can lead to putting undue emphasis on a clinical feature
Slow Thinking Example Framework
- Collect Data and distil into pertinent positives and negatives
- Create a Problem Representation
- Search for and selection of Illness Scripts through a Diagnostic Schema
- Diagnosis;
Diagnostic Error
The "big three" for diagnostic error are cancer, infection, and vascular Events. These account for three quarters of of serious misdiagnosis related harms. Rates of diagnostic error for these range from 2.2% (myocardial infarction) to 62% (spinal abscess), median of 13.6%. Misdiagnosis harms range from 1.2% (MI) to 35.6% (spinal abscess), median of 5.2%.
Most people will experience a diagnostic error in their lifetime. Most diagnostic errors occur through flaws in clinical reasoning skills. This is through deficiencies in data collection, data integration, data verification, leading to premature diagnostic closure.
Common cognitive biases include
- Overestimation - similar to expectations of high stock returns among investors.
- Base rate neglect - true base rates are usually lower than expected
- Anchoring bias - reflects experiences that represent improbable events.
- Confirmation bias - looking for evidence to fit original hypothesis while ignoring evidence that refutes it.
78% would treat cardiac ischaemia when a positive test result places their patient at 11% of less chance of disease.[3]
Competencies in Diagnosis
Olson et al published an important paper on the foundational concepts and core competencies of modern diagnosis. [4]
Foundational Concepts
- .The primacy of medical knowledge
- The dual-processing paradigm as a framework for understanding clinical reasoning
- The value of rational thought and reflection
- The value of experience and of feedback: learning from outcomes of decisions
- The dynamic nature of diagnosis ā the inevitable problems of uncertainty and complexity
- The inherent power of teamwork, of patient engagement, and of health information technology
- The relevancy of human factors and āthe systemā in determining diagnostic performance
- The limits and biases of human cognition
- The value of recognising high risk and āred flagā situations
- The need to prioritise and triage appropriately
- The need to focus on the needs of the patient
- Assessment of diagnosis should include measures of skillful differential diagnosis and diagnostic efficiency
Desirable Attributes are Courage, Humility, Empathy, Flexibility, Integrity, Intellectual autonomy, Kindness, Persistence, Professionalism, Resilience and adaptability, Tolerance of uncertainty, Skepticism, Curiosity, Respect, Patience
Individual Competencies
- Collect key clinical findings to inform hypotheses
- Formulate problem representation
- Correctly prioritise red flag diagnoses
- Create and prioritise a differential diagnosis
- Use support tools including checklists and second opinions
- Use strategies to mitigate cognitive bias.
Team-based Competencies
- Engage with patient and family values and preferences, share uncertainty
- Collaborate with other health care professionals
- Safely transfer care, close loop on test result communication.
- Mitigate system factors that detract from diagnostic quality and safety
- Advance a culture of diagnostic safety with continuous learning about diagnostic performance
- Disclose diagnostic errors and missed opportunities to patients and team members
Checklists
More than 40 biases but most lead to a single pathway where the doctor fails to generate an adequate differential diagnosis or even consider the correct one as a possibility.
Most common reason for diagnostic error is āI just didnāt think of it.ā Using diagnostic checklists may improve diagnostic performance in difficult cases.
General Checklist
- Did I just accept the first diagnosis to mind?
- Did the patient come with a previous diagnosis?
- Should I review patient records before they leave?
- Is there anything that doesnāt fit with the diagnosis?
- Did I do the history, exam, and review the imaging myself?
- Where they seen recently for the same problem? What was done and what has changed?
- Any external pressures?
Clinically Oriented Checklist
This type of list has specific conditions to consider for different presenting complaints. The checklist may highlight "do not miss" and "commonly missed" conditions. See Portal:Differential diagnoses. For example, a checklist for neuropathic arm pain:
- Spinal cord injury
- Cervical Radicular Pain
- Median Nerve
- Ulnar Nerve
- Cubital Tunnel Syndrome (Ulnar neuropathy at the elbow)
- Guyon's Canal Syndrome
- Radial Nerve
- Radial Neuropathy at the Spiral Groove (Saturday Night Palsy)
- Posterior Interosseous Nerve Entrapment (at arcade of Frohse)
- Wartenberg Syndrome (superficial radial nerve at the distal forearm)
- Humeral Shaft Fracture
- Other Peripheral Nerve Lesions
- Suprascapular Nerve Entrapment (at suprascapular notch or spinoglenoid notch)
- Shoulder Dislocation (Axillary nerve)
- Long Thoracic Nerve Injury
- Lateral Antebrachial Cutaneous Nerve Entrapment
- Brachial Plexus Lesions
- Neuralgic Amyotrophy (Parsonage-Turner syndrome)
- Neurogenic Thoracic Outlet Syndrome
- Erb-Duchenne Palsy
- Klumpke's Palsy
- Burner or stinger
- Backpacker's palsy
- Traumatic nerve root avulsion
- Hereditary Neuralgic Amyotrophy
- Neoplasms
- Radiation-induced brachial plexopathy
- Iatrogenic plexopathies (e.g. medial brachial fascial compartment syndrome)
- Diabetic-related brachial plexopathy
- Systemic
- Thalamic Pain Syndrome
- Hemiplegic migraine
- Focal sensory seizures
- Multiple sclerosis
- Axillary vein thrombosis or Paget-Schroetter disease
- Fibromyalgia or Myofascial Pain Syndrome
- Herpes Zoster
- Mononeuritis Multiplex
- Multifocal Motor Neuropathy
References
- ā Lim, Yuan Z.; Chou, Louisa; Au, Rebecca Tm; Seneviwickrama, Kl Maheeka D.; Cicuttini, Flavia M.; Briggs, Andrew M.; Sullivan, Kaye; Urquhart, Donna M.; Wluka, Anita E. (2019-07). "People with low back pain want clear, consistent and personalised information on prognosis, treatment options and self-management strategies: a systematic review". Journal of Physiotherapy. 65 (3): 124ā135. doi:10.1016/j.jphys.2019.05.010. ISSN 1836-9561. PMID 31227280. Check date values in:
|date=
(help) - ā Verbeek, Jos; Sengers, Marie-JosĆ©; Riemens, Linda; Haafkens, Joke (2004-10-15). "Patient expectations of treatment for back pain: a systematic review of qualitative and quantitative studies". Spine. 29 (20): 2309ā2318. doi:10.1097/01.brs.0000142007.38256.7f. ISSN 1528-1159. PMID 15480147.
- ā Morgan, Daniel J.; Pineles, Lisa; Owczarzak, Jill; Magder, Larry; Scherer, Laura; Brown, Jessica P.; Pfeiffer, Chris; Terndrup, Chris; Leykum, Luci; Feldstein, David; Foy, Andrew (2021-06-01). "Accuracy of Practitioner Estimates of Probability of Diagnosis Before and After Testing". JAMA internal medicine. 181 (6): 747ā755. doi:10.1001/jamainternmed.2021.0269. ISSN 2168-6114. PMC 8022260. PMID 33818595.
- ā Olson, Andrew; Rencic, Joseph; Cosby, Karen; Rusz, Diana; Papa, Frank; Croskerry, Pat; Zierler, Brenda; Harkless, Gene; Giuliano, Michael A.; Schoenbaum, Stephen; Colford, Cristin (2019-11-26). "Competencies for improving diagnosis: an interprofessional framework for education and training in health care". Diagnosis (Berlin, Germany). 6 (4): 335ā341. doi:10.1515/dx-2018-0107. ISSN 2194-802X. PMID 31271549.