Differential Diagnosis for Primary Practice.

Differential Diagnosis for Primary Practice Jamison JR. Philadelphia, PA 19106-3399, Churchill Livingstone Inc, 1999, paperback, 498 pp, $37.50.

This text is designed for the medical practitioner in a primary care setting, such as a family or general practitioner, but the information is also valuable to physical therapists in general practice. The text provides tools for deciding whether a patient's symptoms require referral for additional medical care or testing. This text does not focus on differential diagnosis for physical therapy-related conditions. Likewise, the focus of the text is not on diagnosis for the purpose of guiding treatment but on identifying the need for medical referral.

The text is divided into 3 sections, each with a different purpose. Part 1 gives principles of diagnosis, and the author provides a model of the diagnostic process and clinical decision making, including the criteria for specificity and sensitivity of tests. It also includes a broad review of drug therapy and how drugs modify a disease process. The drug therapy chapter reviews the actions of commonly prescribed medications, but it requires some prior pharmacologic knowledge. This first section is broad enough to be useful for any medical professional with some background in clinical practice. The text is easy to read and makes finding pertinent information simple.

Part 2 provides decision-making algorithms for 58 common complaints, ranging from abdominal pain to wheezing. The likely sources of symptoms as well as findings that require referral are included for each complaint. Referred pain patterns are well described for each pertinent complaint in part 2. For example, sources of abdominal pain (eg, visceral, referred) are reviewed in the abdominal pain section. The algorithm format is an especially appropriate method to present the information in part 2. These well-designed algorithms are visually easy to read and they identify many possible diagnoses.

Part 3 is an alphabetical glossary of many medical conditions and is intended to be used with part 2. As the clinician goes through the algorithm for the presenting complaint and finds a possible "diagnosis," he or she is reminded to go to part 3 to look up the key indicators for this specific medical condition.

If the text is used as intended--that is, to screen for medical conditions that require referral--there are few limitations. If physical therapists try to use the text to help arrive at a physical therapy diagnosis, they will be disappointed. For the conditions that lend themselves to physical therapy (eg, backache, joint and limb pain, tremor, unsteadiness, and weakness), the endpoints of the algorithm are vague, ending with spinal dysfunction for example. However, a physical therapist using the text to decide whether to refer a patient for a medical condition would find both the content and format useful. The text assumes that the referral is to another medical specialist for further testing, and does not consider referrals to other health care professionals such as physical therapists. Although it is disappointing that physical therapy is not considered a referral, I think this is more a limitation of clinical perspective rather than a limitation of the text. The author practices in Australia where referral and practice patterns in medicine and physical therapy may be different.

Although the book is not intended as a physical therapy text, it would be useful for professional or postprofessional physical therapist educators teaching differential diagnosis and appropriate referral. It could serve as a reasonable supplement to other differential diagnosis texts. Additionally, the text could be a nice reference in physical therapy clinics, especially those in direct-access states. The algorithms could be adapted for specific practice patterns.

In summary, the purpose of this text is to help the clinician identify symptoms of medical conditions that require referral to a physician or specialist. The decision-making models and algorithms are excellent learning and clinical tools.

Susan Scherer, PT University of Colorado Health Sciences Center Denver, Cold

Ms Scherer is Assistant Professor in the Physical Therapy Program. Her research interests include pulmonary and transplant rehabilitation.