Phương pháp tiếp cận dựa trên hội chứng Efim Benenson (auth) để chẩn đoán một hướng dẫn thực hành Springer verlag london (2013)

Efim Benenson

Syndromebased Approach
to Diagnosis

A Practical Guide

123


Syndrome-based Approach to Diagnosis



Efim Benenson

Syndrome-based Approach
to Diagnosis
A Practical Guide


Efim Benenson
Department of Internal Medicine
and Rheumatology
University of Cologne
Cologne
Germany

ISBN 978-1-4471-4732-9
ISBN 978-1-4471-4733-6
DOI 10.1007/978-1-4471-4733-6

Springer London Heidelberg New York Dordrecht

(eBook)

Library of Congress Control Number: 2013933289
© Springer-Verlag London 2013
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Thanks for their invaluable support to:
Dr. med. Anna Schmidt (Benenson)

Ursula Voigt-Pfeil, Editor
Beverley Taylor, Translation



Preface

Introduction to an Alternative Clinical Teaching Strategy
Many young, inexperienced doctors have difficulty pinpointing a diagnosis: Is it a condition to which certain diseases could belong or a disease definable in line with certain
criteria? How can I apply my basic knowledge of diseases to a real patient? How can I
find the correct diagnosis for a disease that I am seeing for the very first time?
The traditional diagnostic pathways conveyed by current methods of teaching –
from visual identification of a disease, from knowledge of diseases, symptoms, or
patterns, to diagnosis – leave certain diagnostic questions unanswered, especially
when first confronted by a particular clinical pattern (Chap. 1). This highlights the
disadvantage of the inductive clinical thinking which is currently taught.
The ideal diagnostic decision is certainly linked to many years of practical experience. The concept of teaching and studying presented in this book (Chaps. 2, 3, 4,
5, and 6) expands on the present mode of tuition, both for vocational and advanced
training methods, to offer an alternative approach to diagnosis. Using an example
from rheumatology [1–3], it demonstrates how diagnostic decision-making and
clinical reasoning can be uniformly structured and exercised.
The characteristic features and keywords to such a didactic concept are:
• The diagnostic decision:
– The discipline is presented as clinical cases (case-based learning) – not as illustrations of a subject but as problems to be solved (problem-based learning).
– Classic textbook content is reorganized into syndromes – as stable combinations of symptoms – mostly with morphological and pathophysiological
backgrounds (Sect. 6.3).
– A basic curriculum (Chap. 4) is presented as main teaching points: symptoms,
syndromes, and diseases.
– Syndromes are linked to the affected morphological structures (targeted diagnostics, or “diagnose to target”) on the one hand, and diseases on the other.
The structured syndromes build a bridge between the symptoms and diseases

and form the foundation for differential diagnosis.
vii


viii

Preface

• Clinical reasoning
– The optimal diagnostic routes: From patient to disease (and not the other way
round), starting with the morphological and pathophysiological manifestations (Sects. 6.1 and 6.2) – a means of “personified diagnostics.”
– A standardized diagnostic program enables findings to be firmly structured on
the basis of morphology and pathology and at the same time allows causal
examination and detailed clinical investigation (Sect. 6.4).
– The question of syndrome or disease is a deductive key to diagnosis.
– Algorithms of clinical reasoning as a link from lead symptoms to syndromes
and from syndromes to diseases (Sect. 6.5).
• Training and teaching:
– The presentation of clinical problems, without an immediate solution, is the
closest and most realistic way of simulating medical practice.
– Active (self-) study (Sect. 6.6) using the didactic approaches described above
allows preclinical and clinical knowledge to be interlinked and stored in the
long-term memory (retention).
– The decision trees of internal medicine (Sects. 8.1, 8.2, 8.3, 8.4, 8.5, 8.6, 8.7,
8.8, 8.9, 8.10, and 8.11) cover all the major teaching units (symptoms, syndromes and diseases) and are linked with the morphological structures, offering compact, basic information at a glance and a quick solution to colleagues
wishing to refresh their memories – an active approach to clinical reasoning.
This concept has been derived from experience and practice in clinical teaching
[4]. It fulfills all the requirements of present clinical teaching strategies and should
be regarded as a means of sharing experience and learning the language of experienced clinicians – especially when it comes to making a diagnosis. The concept is
primarily a transition, from conveying knowledge about diseases, descriptive-nosological language, and inductive diagnostic pathways, to “learning by doing,” with

case-based decisions, structured syndromes, and structured clinical reasoning,
closely combined with expertise and its application. It offers lecturers an alternative
training concept in their teaching, at the same time as offering students a model for
self-study and for learning how to think in clinical terms.
This training concept is suitable as:
•
•
•
•
•

A self-assessment test
Study program (self-study and case-based study)
Basic program covering all the major teaching objectives in a clinical discipline
A guideline and educational framework for differential diagnosis
A collection of individual therapeutic options (with presentation of clinical
cases)

In these times of unlimited access to information and reduced hours of teaching,
there is, in my opinion, a need for new styles of textbooks for active and practical
self-study. Every day, new diagnostic cases present themselves for examination that
far exceed the boundaries of our knowledge and our specialties. Decision trees for


Preface

ix

most disciplines of internal medicine are included in this teaching concept, as a
stable construct for morphologically oriented diagnostics (“diagnose to target”),

together with a framework for differential diagnosis.
The educational background to this concept can be applied to other clinical
disciplines. Thus, I call upon my young colleagues to gather information on their
clinical cases during their daily work – as the idea behind this concept – in order to
achieve a clear perspective in their specialized fields. The stimulus is provided by
this book and by the books E. Benenson Rheumatology (German edition), Shaker
Media, Aachen, 2009 [1], and Rheumatology, Springer, London, 2011 [2, 3].

References
1. Benenson E. Rheumatology. Syndromes and algorithms. A textbook and practical guide for
doctors, rheumatologists and students. Shaker Media, 2009 [German]
2. Benenson E. Rheumatology. Symptoms and syndromes. London: Springer; 2011.
3. Benenson E. Rheumatology. Clinical scenarios. London: Springer; 2011.
4. Benenson E. A system for preparing internal medicine at the medical institutes and through
internship. Ter Arkh. 1989; 61:139–43 [Russian].



Acknowledgements

My Russian teacher in the clinic, rheumatology, and teaching
Halina A. Marmolevskaj, MD Professor of Medicine (Swerdlowsk, Perm)
Georgy A. Smolenski, Assistant Professor (Perm)
Valentina A. Nassonova, MD Professor of Medicine (Moscow)

xi



Contents

Part I

The Methodical Basis for Practical Clinical Teaching

1 Two Principles and Two Diagnostic Pathways for Clinical
Teaching and Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3

2 Clinical Didactics and the Systemic Problems
of Clinical Teaching . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

13

3 Objectives Central to Clinical Teaching . . . . . . . . . . . . . . . . . . . . . . . . .
3.1 How Does the Targeted Diagnostic Decision “Work”? . . . . . . . .

17
19

4 Practice-Oriented, Basic Knowledge of a Clinical Discipline
or the Curriculum of Practical Clinical Teaching
(with Clinical Examples) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

21

5 Training Levels to Dictate the Standard of Education . . . . . . . . . . . . . .

29

6 New Didactic Approaches to Clinical Teaching . . . . . . . . . . . . . . . . . . .
6.1 Starting with Morphological and Pathophysiological
Manifestations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6.2 From Patient to Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6.3 Syndrome-Oriented Organization of Diseases . . . . . . . . . . . . . . . .
6.3.1 The Language of Syndromes Versus Nosology . . . . . . . .
6.4 Clinical Reasoning in Practical Teaching
(Diagnostic Decision-Making Skills) . . . . . . . . . . . . . . . . . . . . . . .
6.5 Diagnostic Algorithms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6.5.1 From Symptom or Syndrome to Disease . . . . . . . . . . . . .
6.5.2 Algorithms from Symptoms to Syndromes,
from Syndromes to Diseases
(Using Figs. 1.1, 1.2, and 1.3). . . . . . . . . . . . . . . . . . . . . .
6.5.3 Formulation of Syndromes . . . . . . . . . . . . . . . . . . . . . . . .

33
34
36
38
39
41
44
45

46
46

xiii

xiv

Contents

6.5.4
6.5.5

Syndrome or Disease?. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Algorithms “Diagnose to Target”
and Structured Knowledge . . . . . . . . . . . . . . . . . . . . . . . .
6.6 Active Learning En Route to a Valid Diagnosis . . . . . . . . . . . . . . .
7 Manuals for Active Self-Study
(Using Rheumatology as an Example) . . . . . . . . . . . . . . . . . . . . . . . . . . .
Part II

47
47
48
53

Basic Structural Program for Internal Medicine at a Glance

8 “Diagnose to Target” in the Setting of Decision Trees . . . . . . . . . . . . . .
8.1 Angiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.2 Endocrinology I: Pancreas, Thyroid, Parathyroid,
and Adrenal Glands. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.3 Endocrinology II: Hypothalamus, Hypophysis,
Neuroendocrine Tumors, and Gonads. . . . . . . . . . . . . . . . . . . . . .
8.4 Gastroenterology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8.5 Hepatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.6 Hematology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.7 Cardiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.8 Nephrology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.9 Pulmonology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.10 Rheumatology I: Arthrology and Nonarticular Rheumatism . . . .
8.11 Rheumatology II: Connective Tissue Disease and Vasculitis . . . .
8.12 Summary: Syndrome-Based Approach
and Structured Clinical Reasoning as a Model
for Self-Study and Training in Clinical Medicine. . . . . . . . . . . . .

59
61

Figure Legends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

107

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

111

65
69
71
75
79
82
86
90

93
95

97


Abbreviations

ACLA
ACTH
ADH
ALL
AML
ANA
ANCA
Anti-Scl-70-antibodies
APS
ARDS
AV
CK
CLL
CML
CMML
CNS
COPD
CRP
CS
CTD
DD
DIC

DM
dsDNA
E.
ENA
ESR
Fig.
FMF
FMS

Anticardiolipin antibody
Adrenocorticotropic hormone
Antidiuretic hormone
Acute lymphatic leukemia
Acute myeloid leukemia
Antinuclear antibody
Antineuthrophil cytoplasmic antibody
Anti-topoisomerase antibody type of antinuclear
antibodies
Antiphospholipid syndrome
Acute respiratory distress syndrome
Atrioventricular
Creatine kinase
Chronic lymphatic leukemia
Chronic myelogenous leukemia
Chronic myelomonocytic leukemia
Central nervous system
Chronic obstructive pulmonary disease
C-reactive protein
Clinical situation
Connective tissue disease

Differential diagnostic
Disseminated intravascular coagulation
Dermatomyositis
Synonym dsRNA
Endocarditis
Extractable antinuclear antigen
Erythrocyte sedimentation rate
Figure
Familial Mediterranean fever
Fibromyalgia syndrome
xv


xvi

FSH
GCA
GH
GN
GnRH
HCG
HIT
HIV
HLA-B27
HUS
IBD
Ig
IHH
JIA
LDH

LE
LH
MALT
MSH
NASH
NET
NSE
OA
OAD
P.
PAD
PAN
PAOD
PBC
PET
pHPT
PM
PMR
PMR
PNH
PNH
PsA
PSC
PSC
PTT
RA
RCS
RES

Abbreviations

Follicle-stimulating hormone
Giant cell arteritis
Growth hormone
Glomerulonephritis
Gonadotropin-releasing hormone
Human chorionic gonadotropin
Heparin induced thrombocytopenia
Human immunodeficiency virus
Human leucocyte antigen
Hemolytic uremic syndrome
Inflammatory bowel disease
Immunoglobulin
Idiopathic hypogonadotropic hypogonadism
Juvenile idiopathic arthritis
Lactate dehydrogenase
Lupus erythematosus
Luteinizing hormone
Mucosa-associated lymphoid tissue
Melanocyte-stimulating hormone
Nonalcoholic steatohepatitis
Neuroendocrine tumors
Neuron specific enolase
Osteoarthritis
Occlusive arterial disease of the extremities
(arteriosclerosis)
Pericarditis
Peripheral arterial disease
Polyarteriitis nodosa
Peripheral artery occlusive disease

Primary biliary cirrhosis
Positron emission tomography
Primary hyperparathyroidism
Polymyositis
Polymyalgia rheumatica
Polymyalgia rheumatica
Paroxysmal nocturnal hemoglobinuria
Paroxysmal nocturnal hemoglobinuria
Psoriatic arthritis
Primary sclerosing cholangitis
Primary sclerosing cholangitis
Partial thromboplastin time
Rheumatoid arthritis
Rheumatology, Clinical Scenarios, E. Benenson,
Springer London, 2011
Reticuloendothelial system (Kupffer cells)


Abbreviations

RHS
RNP
RSS
SIADH
SLE
Sm
SSc
sy
TB
TSH

TT
TTP
UC
V
WPW

xvii

Reticular-hystiocytic system
Ribonucleoprotein
Rheumatology, Symptoms and Syndromes, E. Benenson,
Springer London, 2011
Syndrome of inappropriate antidiuretic hormone
hypersecretion
Systemic lupus erythematosus
Smith antigen
Systemic sclerosis
Syndrome
Tuberculosis
Thyroid-stimulating hormone
Thrombin time
Thrombotic thrombocytopenic purpura
Ulcus carcinoma
Vasculitis
Wolff-Parkinson-White syndrome


Part I

The Methodical Basis for

Practical Clinical Teaching

This alternative teaching and training concept presents the standardized principles
of clinical teaching for students, physicians, and specialists in all disciplines (Chap.
1), integrated objectives (Chap. 3), and major teaching units (in addition to recognized symptoms and diseases) in the form of structured syndromes which are linked
to the affected structures and should be newly defined for each clinical specialty.
The syndrome-oriented organization of diseases helps to define the fundamental
expertise required of each clinical discipline (Chap. 4) – knowledge that every physician should possess in order to correctly identify and interpret such diseases. This
system of study at the same time allows the existing systemic shortcomings of practical clinical teaching to be overcome (Chap. 2) and in doing so achieves a higher
standard of training (Chap. 5). The new didactic concepts (Chap. 6) unite all the
components of this study system (targets, basic expertise, methods, including structured clinical reasoning and evaluation) with one another and with clinical
practice.
Thus, alternative diagnostic pathways and clinical reasoning are presented as a
framework for differential diagnosis and for developing clinical thought processes,
as well as providing a model for clinical teaching. This system of study, which is
oriented to practical objectives, should be integrated into classic clinical teaching
and practice as early on as possible.


Chapter 1

Two Principles and Two Diagnostic Pathways
for Clinical Teaching and Practice

• The characteristics of the standard classical descriptive-nosological approach to
diagnosis are the primary knowledge about diseases, the inductive route from
symptoms or disease pattern to diagnosis, and ultimately the recognition or
visual diagnosis of the disease. Here, the emphasis is placed on experience, a
good memory, and associations.
• The characteristics of the alternative teaching approach to diagnosis are syndromes as the main teaching points (together with symptoms and diseases),

structured knowledge, and structured clinical reasoning, all of which are based
on morphology and pathophysiology. The emphasis is placed in this case on
practical training via syndrome language and learning to “think clinically.”
The words of wisdom from Johann Wolfgang von Goethe – “Knowing is not
enough, we must apply” – are the guiding principle of this didactic concept.
The diagnostic decision is pivotal to clinical practice and teaching and includes
the question of what is learned and how. Knowledge of diseases is mostly conveyed
as part of the training concept, yet in everyday practice it is essential to apply such
knowledge in order to solve problems.
Here we discover, ultimately, how such knowledge and its application to specific
clinical scenarios can be combined when making diagnostic decisions and solving
problems. This is the actual objective of rational clinical didactics. Let us use Figs. 1.1,
1.2, and 1.3 as an example: How can I find the diagnosis for these pictures?
Such a question is easy to answer after many years of clinical practice, but also
much sooner – which is precisely the aim of this concept – with the help of such new
approaches to clinical teaching.
Let us first attempt to unravel the images in the conventional manner:
In the majority of cases the physician must gather together the patterns composed of the
history and physical findings. He compares these patterns with the pictures stored in his
memory and subsequently develops diagnostic theories [1].

Using the pattern, it is not only the diagnosis but also the correct means of clinical
reasoning that are conveyed [2, 3].

E. Benenson, Syndrome-based Approach to Diagnosis,
DOI 10.1007/978-1-4471-4733-6_1, © Springer-Verlag London 2013

3

4

1 Two Principles and Two Diagnostic Pathways for Clinical Teaching and Practice

Fig. 1.1 See Appendix A

Using another inductive key, screening is performed on the cardinal symptom(s)
or indicative laboratory or radiological finding(s). This diagnostic pathway –
from symptom or disease pattern to diagnosis – reveals precisely the pivotal differences in knowledge (of well-known diseases) and its application when it
comes to ascertaining an individual diagnosis and offers an alternative to the
deductive reasoning of experienced physicians, namely, from patient to disease
and back.
The two didactic principles and two diagnostic pathways can be used when making a diagnosis and should be balanced out during clinical training by teaching the
language of syndromes and structured thinking.
The nosological principle (nosos, Greek for disease) can be described as the
native language of clinical teaching, expressly conveying the acquisition of knowledge that permits us to recognize a disease (embodying training level 1; see Chap. 5)
and recall it (training level 2). These diagnostic pathways are always used by students and junior physicians, but frequently also by experienced physicians.


1 Two Principles and Two Diagnostic Pathways for Clinical Teaching and Practice

5

Fig. 1.2 See Appendix A

Nosological language is in fact very practical: The symptoms or syndromes that are
of diagnostic value – referred to as diagnostic criteria – are recognized. It is necessary to have once seen, read, or heard about them and above all to have retained them
so that they can be recalled at just the right moment. This does not always work in
typical situations and hardly functions at all in an untypical setting. With this in
mind, let us look again at Figs. 1.1, 1.2, and 1.3. Emphasis is placed on knowledge

of diseases, one’s own experience, associations, analogies, and memory. Such reasoning has quite rightly found its place in several fundamental textbooks and compendia as a “clear and up-to-date source of information for everyday clinical practice”
[4], but has its deductive limitations because patterns must always be found by
selecting the findings in order to correctly interpret the unknown clinical pictures or
new constellations. A classic example is the diagnostic pathway from symptom or
syndrome to disease [5–7].
Within the context of traditional didactic approaches, preference is given to the
symptomatological and nosological route from symptom to diagnosis (see Chap. 1).
It is based on the psychology of learning: “A leading symptom…not only leads to a
suspected diagnosis, key examinations corresponding to the leading symptom and
to the diagnostic meaning of the symptom, but also leads to clinical pictures” [8].
Such a principle and diagnostic pathway – from symptom or from syndrome to
disease – are the basis of current teaching practice. Most textbooks and advanced
training courses, as well as the flood of publications on the Internet, present an


6

1 Two Principles and Two Diagnostic Pathways for Clinical Teaching and Practice

Fig. 1.3 See Appendix A

informative and descriptive key. This symptomatological/nosological avenue serves
the present method of clinical didactics.
The main goal here – clinical reasoning – is also conveyed along the lines of this
principle, using clinical examples and detailed considerations of false medical reasoning [3]. This wonderful and unique analysis of cognitive medical errors is caserelated and considerably enriches us in our clinical experience. However, it allows
few conclusions to be drawn as concerns other everyday cases: For example, which
inductive key should be used to explain Figs. 1.1, 1.2, and 1.3, from the initial step
through to the suspected diagnosis?
Clinical reasoning using the principle of pattern analogy and the symptomatological/nosological approach hardly allows for the requisite scope of study and training
in terms of morphologically and pathophysiologically based clinical reasoning, as

1 Two Principles and Two Diagnostic Pathways for Clinical Teaching and Practice

7

the utmost priority in clinical practice and an important element of clinical experience which can lead to individual problem-solving and diagnosis, respectively.
Based on descriptive reasoning and the nosological teaching concept, a diagnosis
is justified on the same terms, irrespective of the nature of the disease. It is almost
as if a template is being used – in an entirely descriptive manner, like the teaching
itself: “Based on the history, clinical and other findings, etc., … the above mentioned diagnosis has been made.” The diagnosis is made in a similar way using the
case-based, multimodal teaching system for training and further education – Casus
(refer to examples on the Internet). In the process, the creativity required of our
medical work, the idiosyncrasies of a disease, the logistics of the clinical diagnostic
decision, and the steps in the diagnostic process are left behind.
Textbooks, lectures, training, and further education usually involve the use of
nosological language, vividly presented in the form of diseases, case histories to
illustrate the topic, or images labeled with the diagnoses. The extensive range of
information available on the Internet is a means of support in a descriptive training
system and supplements the data examined to date. All in all, there is an almost
limitless supply of information from a bottomless chest, permitting the identification
of diseases in everyday practice in which the half-life for contemporary medical
knowledge is known to be only 6–10 years. The positive aspects of this latest era of
information, however, can hardly help to achieve the primary objectives of clinical
training, namely, to identify the individual diagnosis.
The value of theoretical knowledge is certainly not to be denigrated here. On the
contrary, theoretical knowledge is of great practical importance (“no work without
knowledge”), particularly as far as innovative diagnostic and therapeutic concepts
are concerned. Wide-ranging experience should, moreover, be put into perspective
if a specific and “unique” case is involved – and this is how each patient should be

regarded. The nosological principle – from symptom to disease – also entails the
goal of “strategic thinking.”
The objective of a textbook should be, rather, to offer the student a functional ‘compass’
that enables him to rapidly orient himself in the most varied of disciplines and situations.
The reader should not be cramming on singular facts, but acquiring strategies [9].

These entirely justified objectives – from symptom to disease – are naturally
only achievable to a limited degree due to the didactic limitations of the nosological
principle. From the didactic and practical viewpoint, the objectives of practical clinical teaching basically cannot be achieved with nosological language and a saturation of information, especially in terms of making a specific diagnosis and developing
clinical reasoning.
The knowledge conveyed in these and many other books is perfectly adequate for
enabling medical students to obtain their university qualification (by passing their
exams) and permitting clinically experienced physicians (in everyday practice) to
achieve success. The didactic question is how to put the first target group in the position of the second during their university training in order that they can effectively
learn and practice medicine at the earliest possible opportunity. This does not appear
to be possible by simply expanding their knowledge.


8

1 Two Principles and Two Diagnostic Pathways for Clinical Teaching and Practice

Vain attempts are made to link this “symptomatological and nosological avenue”
and pattern of clinical thinking to reveal trends in medical teaching and newly
designed, optional methods of problem-based learning (PBL) [10]. In reality, the
principles, levels, and methods of clinical teaching are varied. Knowledge of diseases and acting “according to patterns” are at the forefront of the classic didactic
concept. PBL is primarily a means of active, practical, case-based study in which
the application of such knowledge is expected. Its principles and methods are currently outlined by these key words: self-directed and case-based learning, teaching
points, clinical reasoning, skills in diagnostic reasoning, simulation, training, and
retention [10–13]. Both concepts – PBL and classical teaching – lack a standardized

format, or systematic didactic method, as to how findings are to be structured and
analyzed. The concept presented here structures the findings on the basis of morphological and pathophysiological knowledge, offering an integrated diagnostic
program and conveying, at the same time, how to “think clinically.”
Figures 1.1, 1.2, and 1.3 belong more or less to the commonly known diseases
described in all books and (post)graduate training courses. But how can we begin to
unravel these images? Which steps and which sequence should be applied?
A case-based diagnostic decision demands not only knowledge, a good memory,
and associative thinking in relation to the clinical cases that have previously been
seen, heard, or read about. Clinical logic demands basic morphological and
pathophysiological knowledge, permitting diseases that are “new” to the physician
to be diagnosed and missing information to be located. To this end, different teaching units (as symptoms and findings) and new didactic approaches are required.
The diagnostic pathway from syndrome to disease likewise relies on the nosological principle if the corresponding disease is to be identified and defined by
means of screening. Once the possibilities of nosological language have been
exhausted in the specific case, a switch should be made to the second diagnostic
principle.
The syndrome principle (syndromes are defined here as stable combinations of
symptoms, from the Greek syn for together and dromos for way or course) has been
developed from the indispensable nosological principle and, advancing beyond the
symptoms, better illustrates the similarities and distinctions between the individual
diseases. The differential diagnostic aspects of syndrome-like diseases are to be
regarded almost as the most difficult and most responsible phase of our clinical
work, though are hardly addressed at all when studying.
This diagnostic syndrome principle, though less favored in clinical teaching, is
the language used by experienced physicians and is a suitable means for acquiring
practical knowledge (training level 3). The broad application of syndromes, as a
basic and universal instrument in clinical teaching, has never to date been discussed
in educational literature. However, syndromes – as clinically, morphologically, and/
or pathophysiologically defined elements or components of diseases – create a better
basis for specific (differential) diagnosis than symptoms which, almost without
exception, have no morphological and/or pathophysiological correlate. Elementary

books on syndrome-related differential diagnosis in internal medicine [14–16] are to
be regarded as a highly important legacy of clinical experience. Due to the wealth of
practical and theoretical knowledge possessed by the authors, they create diagnostic