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The Diagnosis. Russell La Forte, M.D. Area Medical Director Internal Medicine. The Diagnosis. Two Meanings Diagnosis = Patient’s Disease Diagnosis = The artful process by which the patient’s problem is uncovered. The Diagnosis. Neither of these is what “coders” mean by “diagnosis”.

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The Diagnosis

Russell La Forte, M.D.

Area Medical Director

Internal Medicine


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The Diagnosis

  • Two Meanings

  • Diagnosis = Patient’s Disease

  • Diagnosis = The artful process by which the patient’s problem is uncovered


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The Diagnosis

  • Neither of these is what “coders” mean by “diagnosis”.

  • Billing forms usually refer to “working hypotheses” or “working diagnoses”


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The “real” Diagnosis

The right answer to the problem

NO uncertainty

Can be difficult to tie to the patient’s problem

Is often never made or even sought

The “working” diagnosis

Conveys the current level of uncertainty

Suggests what work-up will lead to “the diagnosis”

What’s the difference


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Examples

  • Hypertension – not a “real” diagnosis

  • Why? Doctors do not understand it sufficiently

  • If you have HTN, you should have a physical examination and lab tests to look for

    • 1. A real diagnosis (about 5 percent of patients)

    • 2. Other “real” diagnoses that are associated with chronically elevated blood pressure. Example – Coronary Artery Disease


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Hypertension

  • Cushing’s disease

  • Mineralcorticoid secreting tumor

  • Secondary hypertension from renal disease

  • Renovascular hypertension

  • Coarctation of the Aorta

  • Pheochromacytoma


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Very vague – complaint based

Less vague – complaint based

Syndrome - usual system specific

Lab based – often organ specific

Abdominal Pain, Rash

Dyspepsia, Dermatitis

PUD, lupus

Elevated liver enzymes

Working Dx - Uncertainty



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Often patients without firm diagnoses present with some change in their symptoms

May or may not be the same disease

Irritable Bowel Syndrome – now complains of blood in stool

Symptom not part of the Syndrome of IBS

Further study indicated

New symptoms


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Irritable Bowel Syndrome Patient change in their symptoms

  • Number one diagnosis now hematochezia, i.e. blood in stools (a working diagnosis)

  • Number two diagnosis now Irritable Bowel…although patient may have told the triage nurse that IBS was the presenting problem


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Symptoms change in their symptoms

Body or Mind?


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Psychiatric Overlay change in their symptoms

All symptoms are in the patient’s mind – the disease may or may not be

  • Most diseases, and all chronic diseases, have psychological components – the sufferer has a mental reaction to the disease

  • Sometimes this reaction is another disease in itself


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Primary Diagnosis change in their symptoms

  • Ideally, this diagnosis is the number one working diagnosis

  • Different doctors will view which of several diagnosis is “primary” differently

  • But, when the problems are related there is usually a common pathophysiologic entity that can be listed


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Example change in their symptoms

  • 54 yo male presents to the Emergency Department after passing out at a local restaurant. Work-up in the Emergency room finds both a bleeding duodenal ulcer and a heart attack. Which diagnosis is primary?


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Possible answers change in their symptoms

  • For Inpatient, pick the one with the higher DRG

  • Ulcer is the primary diagnosis.

  • Myocardial Infarction is the diagnosis.


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Duodenal Ulcer change in their symptoms

  • That’s what caused the heart attack, and timing is everything.

  • Underlying or ultimate cause

  • You may never talk the stomach specialist out of it either.


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Myocardial Infarction change in their symptoms

  • If the patient hadn’t had the heart attack, they wouldn’t have passed out. You will never talk the cardiologist out of it either.


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The Right Answer change in their symptoms

  • “Passing out” is the best working diagnosis. Therefore, I would choose syncope complicated by the secondary diagnoses of myocardial infarction and bleeding Duodenal Ulcer.


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Diagnostic Processes change in their symptoms

  • The history and physical examination

    • The hypotheses are generated at this point

    • Often, characteristic findings are present that lead to a “real’ diagnosis being made


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Chief Complaint change in their symptoms

  • What ‘the diagnosis” working or real seeks to explain

  • Sometimes the patient doesn’t have a complaint

  • But they did and that is the reason they are there. They now have a diagnosis and are there for follow-up.

  • Diabetes comes to mind


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More than one diagnosis change in their symptoms

  • If the patient has a complaint, then the diagnosis that explains that one is primary

  • Otherwise, put the one most addressed in the plan first.

  • Or, the most serious one


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Mrs. Y change in their symptoms

  • CC: I don’t know, I feel fine

  • PMHX: HTN for 20 yrs, AODM for 15 yr, hyperlipidemia, OA, CAD with recent abn’l cath, HA, dyspepsia, tobacco abuse, seizures

  • History, physical, labs are all ok.


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Ordering diagnosis change in their symptoms

  • What is the proper order of diagnoses?

  • Depends on the doctor and the day

  • Endo – AODM

  • Cardiology – CAD

  • Neurologist - seizures


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Skinning the Cat change in their symptoms

  • CAD is the number one diagnosis

  • First, there has been a recently abn’l finding

  • More importantly, it is a serious problem, in and of itself

  • The others are not particularly serious (OA) or are “diseases” invented to help us prevent serious problems like CAD (HTN, hyperlipidemia, and, to a lesser extent, AODM)


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But… change in their symptoms

  • The patient was complaining of their joint pain, and you still put CAD as the number one diagnosis.

  • Eclipse

  • I didn’t do anything about the OA except listen to the complaint.

  • I personally called the CT surgeon because they need an operation.


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Multiple Complaints – type 1 change in their symptoms

  • Mr. P is a 34 yo male that complains of chest pain, nightly erectile dysfunction, depression, headache, ingrown toenails, and anal pruritus.

  • “Depression” is the number one diagnosis.

  • Other diagnoses are so colored by psychiatric problems that they are not really explainable otherwise.

  • Further work-up, such as finding he has a serious cardiac defect may change this.


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Multiple complaints - 2 change in their symptoms

  • Ms. Q is a 90 yo spinstress with HTN, AODM, OA, depression and abdominal pain for 20 yrs without abn’l findings on examination.

  • Her arthritis keeps her up at night

  • Her blood sugar is chronically elevated – not too bad

  • Her blood pressure remains abn’l on four drugs

  • Her stomach hurts daily


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It’s Hard to Be Humble change in their symptoms

  • Whatever you pick as number one, somebody can explain to you why you are wrong.

  • Pick the one that the doctor did the most work on as number one. The doctor simply must choose which is the most important.

  • In this case it would be AODM.


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More than One Working Diagnosis change in their symptoms

  • Importance of explaining as much as one can with one hypothesis

  • Eventually, as people age, they will pile up diagnoses (both real and working).


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Diagnosis Deferred change in their symptoms

  • I bet you can’t bill it as that, but deferral is very common in the art of medicine.

  • IN other words, the patient presents early in the course of a process, and the diagnosis can’t be made on the bases of H+P. The condition is unlikely serious enough to be worked up further at this point.

  • Most people, including doctors, don’t necessarily realize they are deferring diagnoses.


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Example change in their symptoms

  • 25 year old male presents with nose bleeds for about one week, mostly of oozing. The patient is concerned about exposures to chemicals at work. He has been using nose spray for a runny nose and notes that this controls the bleeding as well. His blood pressure was high at work (he has high blood pressure). Unremarkable physical examination except three shallow ulcers inside the nose – two on the left, one on the right.


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  • Now, we could decide to make an exact diagnoses by doing some tests –nasal smears and biopsies. I felt reasonably confident that he had recently had a cold, and the nose spray he used contributed to the ulcers, although the immediate effect is to decrease bleeding. I did nothing further and told him to call back if he wasn’t better in a week off the nose spray.


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Therapeutic Trial some tests –nasal smears and biopsies. I felt reasonably confident that he had recently had a cold, and the nose spray he used contributed to the ulcers, although the immediate effect is to decrease bleeding. I did nothing further and told him to call back if he wasn’t better in a week off the nose spray.

  • A change in medication or treatment is made to assist in making the correct diagnosis. By stopping Mr. X’s medicine, he was taking a therapeutic trial.


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