Rules regarding differential diagnosis need to be defined. Differential diagnosis is not an academic exercise. It is a clinically significant documentation of the physician's thinking. When a physician writes "chest wall pain, rule out myocardial ischemia" or "gastroenteritis, rule out appendicitis," potentially life-threatening entities must be ruled out before the patient is permitted to leave the site. Failure to do so may lead to the patient's death.
The more common of the life-threatening entities should be recorded. The esoteric diagnosis need not be recorded initially. A carefully thought out history and physical will guide the physician. If the more common entities are ruled out, then additional diagnostic possibilities should be considered. In the case of chest wall pain, historical facts may make it necessary to first rule out myocardial ischemia, pleurisy, and pulmonary emboli. As new information is gathered, it may become necessary to rule out dissecting thoracic aortic aneurysm, metastatic cancer, herpes zoster, and so on. In today's world of cost containment and cost-effective medicine, a logical sequential approach to differential diagnosis should be employed and documented. However, time is of the essence.
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