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Difficult Diagnosis

William R. Best, MD
JAMA. 1985;253(24):3609. doi:10.1001/jama.1985.03350480119040.
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A number of academic physicians from various specialties collaborated in the diagnostic approach to 68 of the most enigmatic clinical presentations that have puzzled the editor, a professor and chairman of family practice. These are arranged in alphabetical order from "Abdominal Pain, Acute" through, among others, "Breast Discharge," "Diarrhea, Chronic," "Failure to Thrive, Infant," "Hyperkalemia and Hypokalemia," "Impotence," "Jaundice," "Pulmonary Nodule, Solitary," "Tinnitus," "Urinary Incontinence," and "Vertigo" to "Weight Loss." Experts in particular fields have thoughtfully considered each topic. They have stressed "high payoff" questions on the medical history, key clues from the physical examination, and some useful branching algorithms. Many useful tables are present.

As an example, "Calf Pain" may be the only sign of a potentially serious venous thrombosis, but in most clinical settings it is explained by one of 17 other mostly benign conditions. Which instances call for the "big guns" and which can be simply dismissed?


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