1) THOU SHALL LOOK FOR A SINGLE CAUSE FOR SEVERAL SYMPTOMS: If the patient is exhibiting several symptoms which appear unrelated, then try to link them all together to one cause. Almost always there is a single diagnosis causing all clinical symptoms rather than several diagnoses causing several symptoms.
2) THOU SHALL GIVE TIME AND REVIEW THOROUGHLY: Most of the time we encounter simple cases. In our busy lives we encounter mostly simple or straightforward cases. Pneumonia, UTI etc. But when a clinical mystery comes along you need to stop and think. I sit down with the chart and promise myself not to stop reading it until I find a solution or headway. Usually within 15 to 20 minutes the bulb in the mind will go off.
3) THOU SHALL HAVE PASSION AND COMPASSION: Put yourself in patients shoes. Imagine how it feels to be sick without a diagnosis. Also remember that you first joined medicine to do the glamorous stuff like solving a tough clinical case.
4) THOU SHALL ASK THY FRIENDS: You may want to anonymously (without violating HIPAA) discuss the case with your colleagues. They may come up with some good idea.
5) THOU SHALL STOP DOING MEDICINE THAT DOES NOT WORK: If your patient is not getting better on a treatment. Do something different. Do not let some treatment continue when it is not working.
6) THOU SHALL ADMIT THY LIMITATIONS: Be honest with your patients. Admit that you don’t know the diagnosis. But reassure them that you will not rest until you find one. They will respect you for being honest.
7) THOU SHALL LISTEN LONG ENOUGH: Do not hesitate to retake the history in a tough clinical case. May be the patient forgot to tell you something. Or may be you did not listen long enough.
8) THOU SHALL LOOK FOR HORSES: Remember the saying “If you hear hoofs, think of horses not Zebras”. More likely you are looking at a common diagnosis with an uncommon presentation, than an uncommon diagnosis with a common presentation.
9) THOU SHALL NOT IGNORE: Just because we are not able to find a diagnosis does not give us a right to ignore it, or call it fibromyalgia. Take all symptoms seriously unless proved otherwise. Ignoring can be a very humbling experience.
10) THOU SHALL CELEBRATE: Once you have cracked a challenging clinical diagnosis, you need to boast, feel good and proud about it. Let it all out, after all you deserve it.