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Licensed Unlicensed Requires Authentication Published by De Gruyter August 21, 2018

The approach to a diagnostic dilemma

  • Daniel Lichtstein and Gauri Agarwal EMAIL logo
From the journal Diagnosis


Diagnostic dilemmas refer to situations in which physicians face a challenging clinical scenario. The goal of our paper is to outline strategies which we have found to be most helpful in the approach to a diagnostic dilemma. We review each strategy and provide illustrative clinical examples. Among the most helpful strategies are performing a thorough history and physical examination (H&P) (including pertinent epidemiological factors and careful medication review), avoidance of non-specific testing and empiric treatment, judicious use of consultants, maintaining an open-mind and humility and ongoing, open communication with your patient.

Corresponding author: Gauri Agarwal, MD, FACP, University of Miami – Medicine, 2500 North Military Trail, Suite 260, Boca Raton, FL 33431, USA

  1. Author contributions: All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission.

  2. Research funding: None declared.

  3. Employment or leadership: None declared.

  4. Honorarium: None declared.

  5. Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.


1. Available at: Accessed: 1 Jul 2018.Search in Google Scholar

2. Cunha BA. The master clinician’s approach to diagnostic reasoning. Am J Med 2017;130:5–7.10.1016/j.amjmed.2016.07.024Search in Google Scholar PubMed

3. Schiff GD, Hasan O, Kim S, Abrams R, Cosby K, Lambert BL, et al. Diagnostic error in medicine: analysis of 583 physician-reported errors. Arch Intern Med 2009;169:1881–7.10.1001/archinternmed.2009.333Search in Google Scholar PubMed

4. Verghese A, Charlton B, Kassirer JP, Ramsey M, Ioannidis JP. Inadequacies of physical examination as a cause of medical errors and adverse events: a collection of vignettes. Am J Med 2015;128:1322–4.e3.10.1016/j.amjmed.2015.06.004Search in Google Scholar PubMed

5. Weed LL. Medical records that guide and teach. N Engl J Med 1968;278:593–600.10.1056/NEJM196803142781105Search in Google Scholar PubMed

6. Custers EJ. Thirty years of illness scripts: theoretical origins and practical applications. Med Teach 2015;37: 457–62.10.3109/0142159X.2014.956052Search in Google Scholar PubMed

7. Lichtstein DM, Herskowitz B. Massive gastrointestinal bleeding from Meckel’s diverticulum in a 91 year old man. South Med J 1998;91:753–4.10.1097/00007611-199808000-00010Search in Google Scholar PubMed

8. Fitzgerald RJ. Medication errors: the importance of an accurate drug history. Br J Clin Pharmacol 2009;67:671–5.10.1111/j.1365-2125.2009.03424.xSearch in Google Scholar PubMed PubMed Central

9. Epstein R. Attending: medicine, mindfulness, and humanity. New York, NY: Simon and Schuster, 2017.Search in Google Scholar

10. Dhaliwal G. Premature closure? Not so fast. BMJ Qual Saf 2017;26:87–9.10.1136/bmjqs-2016-005267Search in Google Scholar PubMed

11. Kleinman A, Eisenberg L, Good B. Culture, illness, and care: clinical lessons from anthropological and cross-cultural research. Ann Intern Med 1978;88:251–88.10.7326/0003-4819-88-2-251Search in Google Scholar PubMed

Received: 2018-05-29
Accepted: 2018-07-12
Published Online: 2018-08-21
Published in Print: 2018-09-25

©2018 Walter de Gruyter GmbH, Berlin/Boston

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