Sometimes we have been treating a patient for a while, know them well, worked through the initial, potential differential diagnoses and the patient is still suffering. Hmmm, what to do next. Some may refer… others may persist. Comfort level important here.
You feel your training is appropriate, so you persist in your evaluation. In these circumstances, I frequently find it very useful to go back to the beginning, the 20,000 ft view.
Take a step back, initiate and elicit a thorough history and physical once again and see if this identifies any new thoughts on an alternative differential or diagnostic test. Very frequently a new list of differentials will emerge and the light bulb will illuminate. Sometimes it won’t. It’s at those moments that a referral to another specialist may be in order. Another set off eyeballs is sometimes revealing too…
What’s your approach to the difficult diagnosis?