According to Web MD’s dictionary, a differential diagnosis is “the determination of which of two or more diseases with similar symptoms is the one from which the patient is suffering, by a systematic comparison and contrasting of the clinical findings”.
An experience I have had with ‘differential diagnoses’ proved to be challenging not due to creating a list of possible diagnoses, but from the challenge of discussing the possible diagnoses with the patient.
My patient came in for denture adjustment of her complete upper and lower dentures. When I set in to complete my head and neck exam, I noticed a sore next to her upper lip (read the post on ASDAblog.com to see the photo). When I asked her about it, she said that “it’d been there for a while” but that she was able to cover it up pretty well with make-up. When I probed how long “a while” was she reported, “at least a year, maybe a year and a half”. She said this was the only sore she’s had like this and that she’d had it looked at before and was told it was an “ingrown hair”. I’m thinking a year and a half is a long time for any sort of ‘sore’ or ingrown hair – so I do the next thing you do at dental school, call for a Path Consult.
Dr. Richard Madden, DDS, comes over to my cube to meet my patient and take a look at the sore. We record a “7mm x 5mm with rolled, firm, and scaly borders, and a central, crater-like depression”. She reported it bled occasionally or leaked a clear fluid and “seems to have gotten bigger”. Based on this we came up with a differential diagnosis of: recurrent ingrown hair, herpes labialis, keratoacanthoma, basal cell carcinoma.
Now I needed to explain our findings, our differential diagnosis, and the need for a medical consultation with the patient. This made me a little uncomfortable. I wasn’t sure how to tell this patient who thinks she just has an ingrown hair and just wants her dentures adjusted, that this facial lesion may actually be a form of cancer. I approach the discussion of the findings and differential diagnoses with a calm voice, honesty, and sincerity. She was a little scared when she heard “possibly basal cell carcinoma” but also expressed gratitude in us taking the time to look at this lesion and that she would follow-up with her medical physician.
I heard back from this patient that the lesion was actually basal cell carcinoma, she was able to have it removed and that the scar is not very noticeable. Additionally, this visit to her medical doctor prompted her to have a full physical evaluation where she was informed she had breast cancer as well. She underwent a double mastectomy surgery and is now home recovering.
From this experience I learned a lot about professionalism and patient interactions. It is important not to shy away from telling the whole truth, even if it’s uncomfortable for you – that is our job now.
While hearing “you may have cancer” will never be comforting, knowing that your dentist is looking out for your health in every way is.
~Katie Divine, Minnesota ’13, Editor-In-Chief
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