Algorithm for Differential Diagnosis of Sleep Disorders in Children

Abstract

Process of solving clinical problems begins with a complaint or chief complaint. This statement begins a cascade of events that occurs very rapidly and, for the experienced clinician, almost instantaneously and unconsciously. Theories about potential underlying etiologies are entertained, and a “list” of possible diagnoses is created that guides all further clinical evaluation and inquiry. Following this key initial encounter with the patient and/or parents, questioning begins (history of the presenting problem). Questions are asked of the parents/patients testing each theory, based on symptoms of possible etiologies known to the clinician. Answers to these questions either support or refute a specific diagnosis. Questioning parents/patients continues until possible diagnoses are eliminated or maintained then ordered on a list of probable diagnoses. When no further questioning can either confirm or refute the presence of symptoms of particular diagnoses, the clinician then moves to reviewing various systems and obtaining other information that may have nothing to do with an initial hypothesis, but this questioning is required for completeness and because there are many sleep-related disorders with overlapping symptoms. Information regarding past medical history, family history, and social history is obtained as the clinician tests the original theories. There comes a point of diminishing returns when further questioning does not move the inquiry into the cause of the complaint further. A physical examination is then performed. Physical findings associated with those theories/etiologies are searched for, and their presence or absence either supports or refutes the theory respectively. Observations of experienced clinicians conducting a clinical evaluation have shown this process is repeated between patients, and data collected by the clinician from each patient is not accomplished in a regimented sequential manner as most history and physical forms and electronic medical records require. In fact, the process is quite rapid, and a comprehensive assessment of patients’ complaints is accomplished in the first quarter of the clinical encounter.