Physical, Neurological, Psychological Evalulations

This block’s last integrated problem solving (IPS) case study dealt with a seven year old boy who presents to a child psychiatrist with behavioral problems, trouble in school, antisocial tendencies, etc. Last week, my group’s analysis of the case file narrowed down our differential to ADHD, but an interesting point was brought up by the group facilitator.

Had this child gone to a family medicine doctor instead of a psychiatrist, would the differential diagnosis be different? Does a physician’s specialty bias which tests/labs are ordered? What if the behavioral problems were caused by a small frontal lobe tumor which would be virtually unresponsive to ADHD treatments?

Psychological problems tend to be the most subjective conditions to diagnose and treat because of the vast gray area. What exactly constitutes ADHD? A quick Google search will provide some general symptoms, but I’m sure the details will vary from specialist to specialist.

At the same time, is it justified to order a brain MRI (>$1000) for all patients who present with any neurological findings, or are we better off with playing the probability game and arguing in favor of ADHD because it’s more common? There’s a true art in maximizing the efficiency of dollars spent in diagnosing a medical condition.

In the end, the facilitator said the best way to approach a given patient is by evaluating his or her physical symptoms, then neurological involvement, and finally psychological status. By doing so, one eliminates possible diagnoses (from easiest to most difficult) in a systematic way.

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