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November 22, 1985

Differential Diagnosis and Heuristics-Reply

Author Affiliations

University of Michigan Medical School Ann Arbor

JAMA. 1985;254(20):2890-2891. doi:10.1001/jama.1985.03360200040011

In Reply.—  We agree with Dr Nardone that in medicine the clinician often uses both a "depth" and "breadth" approach in evaluating a patient's clinical findings. Using a "depth" approach, the clinician probes for information in a vertical, "aggressive" style within one disease in order to confirm or disconfirm his or her primary hypothesis. Using a "breadth" approach, the clinician probes in a horizontal, "cautious" style across competing hypotheses in a differential diagnosis. Many of us believe that these depth-breadth strategies are indeed complementary, and that the clinician frequently pursues a sequential pattern in which the initial symptom (eg, pleuritic chest pain) is pursued along a vertical path by asking questions designed to confirm or rule out the primary hypothesis (eg, pulmonary embolism; was the patient immobilized?; are there calf or thigh symptoms?). The clinician may then shift to a broader "cautious" questioning mode to examine whether another diagnostic hypothesis