THE DIAGNOSTIC PROCESS

最近、臨床推論におけるムーブについて考えていたが、何も車輪の再発明をするまでもなく、右掲本の冒頭に「診断のプロセス」についての要約があることに、いまさらながら気がついた。初版本は読んでいたが、最近の認知心理学の進歩なども取り入れた記述に改訂されているので、買いの一冊。日本語に拘らなければ、kindle版の"Symptom to Diagnosis: An Evidence Based Guide, Second Edition (LANGE Clinical Medicine) " が、45%引きで手に入る。該当部分を引用する。

Constructing a differential diagnosis, choosing diagnostic tests, and interpreting the results are key skills for all physicians and are some of the primary new skills medical students begin to learn during their third year. The diagnostic process, often called clinical reasoning, is complex, but it can be broken down into a series of steps, diagrammed in Figure 1–1.
Step 1: Data AcquisitionData you acquire through your history and physical exam, sometimes accompanied by preliminary laboratory tests, form the basis for your initial diagnostic reasoning. Your reasoning will be faulty unless you start with accurate data, so the prerequisite for obtaining valid data is well developed interviewing and physical examination skills.
Step 2: Accurate Problem RepresentationThis step consists of developing a “problem synthesis statement,” a concise, single sentence summary of the main clinical problem and its associated context.
Clinical problems are symptoms, physical findings, test abnormalities, or health conditions for which diagnostic evaluation could be undertaken. The problem synthesis statement is meant to focus on the patient's most important problem, usually the chief complaint.
Context refers to pivotal points, generally one of a pair of opposing descriptors used to compare and contrast diagnoses or clinical characteristics; for example, old versus new headache, unilateral versus bilateral edema, smoker versus nonsmoker. Extracting pivotal points from the history and physical exam enables the clinician to focus a broad differential diagnosis to a more limited set of diagnoses pertinent to that particular patient. The prerequisite for being able to construct an accurate problem representation is knowledge of the pivotal points for specific clinical problems.
Step 3: Develop a Complete, Framed Differential DiagnosisThe process for developing a differential diagnosis will be discussed later in this chapter; subsequent chapters will present comprehensive, framed differential diagnoses specific for each problem discussed.
Step 4: Prioritize the Differential DiagnosisNot all diagnoses in a given differential are equally likely, or equally important. In order to effectively select diagnostic tests and therapies, it is necessary to select a “leading hypothesis,” a “must not miss” hypothesis, and other “active alternative hypotheses” (see full discussion later). The prerequisites for this step are knowledge of pivotal points; typical or “textbook” presentations of disease; the variability of disease presentation; and which diseases are life-threatening, very common, or easily treatable. It is also necessary to know how to estimate pretest probability, and which history, physical, or laboratory findings are so specific for a disease they are diagnostic; in other words, such findings are “fingerprints” for the disease.
Step 5: Test Your HypothesisSometimes you are certain about the diagnosis based on the initial data and proceed to treatment. Most of the time, however, you require additional data to confirm your diagnostic hypotheses; in other words, you need to order diagnostic tests. Whenever you do so, you should understand how much the test will change the probability the patient has the disease in question. The prerequisite for this step is knowing the sensitivity, specificity and likelihood ratios (LRs) of the tests you have chosen, knowing how to interpret these test characteristics, and understanding how to determine posttest probability using pretest probabilities and LRs.
Step 6: Review and Reprioritize the Differential DiagnosisRemember, ruling out a disease is usually not enough; you must also determine the cause of the patient's symptom. For example, you may have eliminated myocardial infarction (MI) as a cause of chest pain, but you still need to determine whether the pain is due to reflux or muscle strain, etc. Whenever you have not made a diagnosis, or when you encounter data that conflict with your original hypotheses, go back to the complete differential diagnosis and reprioritize it, taking the new data into consideration. Failure to carry out this step is one of the most common diagnostic errors made by clinicians and is called “premature closure.”
Step 7: Test the New HypothesesRepeat the process until a diagnosis is reached.