Let me give you a sense of what I do for a living. In My Humble Opinion had a fantastic post yesturday titled Four Patients It should give you a great sense on why having a head of the ship is so important.
Let me give you a case history:
I had a very pleasant mid 80's fully functional female present with acute onset of transient garbled speech, confusion, "dizziness", unstable gait/ dizziness ever since her right carotid endarterectomy was done for critical carotid stenosis in June of last year.
The patient also describes intermittent boughts of diarrhea and right sided abdominal pain, which is very non specific.
To add to the difficulty, she is unable to clarify or quantify her dizziness, a very nondescript term that means different things to different people and means everything to doctors.
Our hospital has a great EMR where in I can search everything very quickly from her 2006 admission:
H+P, consult notes, DC summary all reviewed
Carotids reviewed
Cardiac Echo Reviewed
Renal Ultasound reviewed
MRI brain reviewed
all labs reviewed
Now, here's an 8o's year old lady that sounds like a slam dunk TIA/mini stroke. But I'm not so sure.
The patient presents with very impressive orthostatis changes. Systolic blood pressure from over 200 to low 100's upon supine-->stand.
I note also that she has acute renal failure with BUN 40's, Cr 1.8 in the absence of any known renal failure, diuretic usage, vomiting or recent diarrhea or anorexia. No ACEi use either.
I also note that her MCV on her CBC is over 100, being around 90 six months ago.
I went back and looked at all the reports from her xrays 6 months ago. MRI brain shows empty sella. This indicates that the pituitary is either shrunk or missing.
The ultrasound of the kidneys was an equivocal test for renal artery stenosis.
The patient has no reported history of hypertension, but has stage II diastolic heart changes on cardiac echo 6 months ago. So she likely DOES have chronic hypertension.
This patient is not a slam dunk TIA. It is farthest from the truth.
After completing my rules of engagement known as Evaluation and Management as defined by the Medicare National Bank (History of present illness, Past medical, family and social history, Review of systems, Physical exam), I come to the medical decision making.
What the hell am I dealing with. Profound orthostasis can present with a TIA like complex, but what is causing her blood pressure to plummet. Is she really just dry as a bone? It's possible. But not for 6 months. The patient described many complaints that cover a wide ranging differential diagnosis, when you throw in the lab and vital abnormalities.
The goal of the differential diagnosis is to break up each complex of signs and symptoms into pockets of disease possibilities. Create a list for each one and then try to see if any of your lists have crossing diagnosis. In this situation, I came up with the following problem list:
ACUTE Problems:
Acute systolic hypertension
Orthostasis (profound)
Garbled speech (transient)
Macrocytic Anemia, a new diagnosis
Acute Renal Failure, with normal baseline renal function
A weak constellation of symptoms that include achy shoulders, jaw fatigue, headaches and vision changes (she is a poor classifier of symptoms)
CHRONIC:
Stage II diastolic dysfunction on prior cardiac echo
Intermittent diarrhea and nonspecific abdominal pain
Hypothyroidism on replacement
Empty sella on prior MRI
Equivocal prior Ultrasound for renal artery stenosis
Prior endarterectomy for TIA
hypercholesterolemia on statin therapy
How does an internist think through these problems? How does the acute problems relate to the known, chronic problems? Well physicians build a differential diagnosis based on all the information obtained. Our ability to build a differential diagnosis is directly dependent on the strength of our training, number of cases seen in our lifetime and the variety of clinical presentations for common and uncommon diseases. Patients rarely presents like a text book.
The building of the differential diagnosis is why we went to medical school and residency and is why an extender will never take over primary care
In this patient I developed the following differential diagnosis:
Adrenal Insufficiency.
Hypothyroidism
B12 Deficiency
Giant Cell Arteritis
Hypertensive crises
TIA
Volume depletion
Renal Artery Stenosis
Amyloidosis
The basis for my differential is as follows:
Adrenal insufficiency: Some of the hallmark complaints are dizzy, low energy, unsteady, abdominal pain. She had high normal potassium levels and low normal sodium levels. And she had high normal eosinophils on her peripheral smear. She also has an empty sella on her MRI, of unclear etiology. So how do I either confirm or exclude the diagnosis? I order a cosyntropin stimulation test where in I draw a random cortisol level, give here a hormone to stimulate her adrenal glands and then check 30 and 60 minute cortisol levels.
Hypothyroidism: She is on thyroid pills. Hypothyroid can do a lot of funny things. So it's always in the differential of just about everything. However, it is also in the differential of macrocytosis, which itself has a fairly limited differential (hypothyroidism, B12 deficiency, liver disease, bone marrow disease, usually myelodysplastic syndrome or other leukemic disorders)
B12 deficiency: Her level 6 months ago was low normal. B12 is an important vitamin necessary for nerve function. It is very common for elderly people to bet deficient. A low B12 can cause neurological changes, mental status changes, neuropathy, weakness and is in the differential of macrocytic anemia.
Giant Cell Arteritis/Temporal Arteritis: This is somewhat of an emergency. Failure to treat can cause permanent blindness. It is a vasculitis where in inflammation of the blood vessels can cause intermittent vision loss, jaw claudication, headaches. It is on a spectrum of disease with Polymyalgia Rheumatica (PMR) that usually presents in old people with bilateral shoulder pains. In my patient, she had some non descript complaints along all these lines and I felt warranted to check her ESR (erythrocyte sedimentation rate) for any signs of systemic inflammation. While not necessary to make the diagnosis, a sed rate over 100 in this clinical setting is almost diagnostic and would warrant immediate treatment with high dose steroids.
Hypertensive Crisis: This is a condition where in very high blood pressures can cause a multitude of complaints. Usually present in the form of delirium, headache, asymmetric focal neurological deficits (TIA type complaints), angina, acute systolic or diastolic heart failure. The very high blood pressure screws up your body. In my patients case, it is quite possible that her garbled speech was the result of a hypertensive TIA in the Broca's centers of the brain. However, the impressive orthostasis certainly wouldn't be consistent with this.
TIA. A garden variety TIA, either hypertension or thrombotic or embolic. Given her history of atherosclerotic vascular disease, her high blood pressure, her diastolic heart. I believe switching her from aspirin to Aggrenox is clinically warranted.
Volume Depletion: She may have nothing more than intravascular volume depletion. Common things are common. But it doesn't justify really high blood pressures.
Renal Artery Stenosis: It can explain really high blood pressures and renal insufficiency, but I'm hard pressed to explain, again, the orthostasis and her macrocytosis
Amyloidosis: No specific reason, except for a thickened heart.
Two of the rules of internal medicine are Common things are common And The most likely explanation is the right explanation.
In my patients situation, I don't yet have a unifying diagnosis to explain all the clinical abnormalities. On occasion, patients present with more than one unifying diagnosis, that breaks the rules we were taught.
This is how internal medicine and most docs in general are taught to think. It is not easy. It takes a lot of time. This patient had subjective complaints that spanned multiple organ systems:
Neurological
Musculoskeletal
Abdominal/GI
She also had objective abnormal findings from multiple organ systems
Kidney
Brain
Blood
Heart
The role of the internist as I have previously said is to put it all together into a unifying diagnosis.
This is how internists think.
This is not, in general, how specialists think
They are special because they know their organ well. Most specialists are so far out from their training from general medicine that asking a cardiologist to evaluate for polymyalgia rheumatica would raise eyebrows of confusion. It would be no where near their differential diagnosis.
This is internal medicine at its finest. It takes time. Lots of it. And to do a great job of managing a patient, not a disease or an organ takes a monstrous effort that demands respect. Unfortunately, this encounter, which took me over an hour to formulate after including my history, physical, review of old records, discussion with family and writing all my orders.
And this encounter at a high complexity visit will pay approximately $185 all inclusive by Medicare for over one hour of complex service.
Two screening colonscopies done in a gastroenterologist's office in an hours time will pay $400, plus facility fees. More if biopsy or polyp removals are done.
So we have an incredibly important role of primary care being decimated by the high cost of school loans, and the opportunity cost of entering other much more lucrative fields of medicine, or no medicine at all.
What we have left are specialists in their organ, but who have neither the ability nor the desire to evaluate the patient as a whole and develop a differential diagnosis that spans across all organ systems.
I don't yet know what the clinical diagnosis(s) will be in this patient. Time will tell.
This Is What I Do For A Living
And this is why your survival depends on primary care survival.
Let me give you a case history:
I had a very pleasant mid 80's fully functional female present with acute onset of transient garbled speech, confusion, "dizziness", unstable gait/ dizziness ever since her right carotid endarterectomy was done for critical carotid stenosis in June of last year.
The patient also describes intermittent boughts of diarrhea and right sided abdominal pain, which is very non specific.
To add to the difficulty, she is unable to clarify or quantify her dizziness, a very nondescript term that means different things to different people and means everything to doctors.
Our hospital has a great EMR where in I can search everything very quickly from her 2006 admission:
H+P, consult notes, DC summary all reviewed
Carotids reviewed
Cardiac Echo Reviewed
Renal Ultasound reviewed
MRI brain reviewed
all labs reviewed
Now, here's an 8o's year old lady that sounds like a slam dunk TIA/mini stroke. But I'm not so sure.
The patient presents with very impressive orthostatis changes. Systolic blood pressure from over 200 to low 100's upon supine-->stand.
I note also that she has acute renal failure with BUN 40's, Cr 1.8 in the absence of any known renal failure, diuretic usage, vomiting or recent diarrhea or anorexia. No ACEi use either.
I also note that her MCV on her CBC is over 100, being around 90 six months ago.
I went back and looked at all the reports from her xrays 6 months ago. MRI brain shows empty sella. This indicates that the pituitary is either shrunk or missing.
The ultrasound of the kidneys was an equivocal test for renal artery stenosis.
The patient has no reported history of hypertension, but has stage II diastolic heart changes on cardiac echo 6 months ago. So she likely DOES have chronic hypertension.
This patient is not a slam dunk TIA. It is farthest from the truth.
After completing my rules of engagement known as Evaluation and Management as defined by the Medicare National Bank (History of present illness, Past medical, family and social history, Review of systems, Physical exam), I come to the medical decision making.
What the hell am I dealing with. Profound orthostasis can present with a TIA like complex, but what is causing her blood pressure to plummet. Is she really just dry as a bone? It's possible. But not for 6 months. The patient described many complaints that cover a wide ranging differential diagnosis, when you throw in the lab and vital abnormalities.
The goal of the differential diagnosis is to break up each complex of signs and symptoms into pockets of disease possibilities. Create a list for each one and then try to see if any of your lists have crossing diagnosis. In this situation, I came up with the following problem list:
ACUTE Problems:
Acute systolic hypertension
Orthostasis (profound)
Garbled speech (transient)
Macrocytic Anemia, a new diagnosis
Acute Renal Failure, with normal baseline renal function
A weak constellation of symptoms that include achy shoulders, jaw fatigue, headaches and vision changes (she is a poor classifier of symptoms)
CHRONIC:
Stage II diastolic dysfunction on prior cardiac echo
Intermittent diarrhea and nonspecific abdominal pain
Hypothyroidism on replacement
Empty sella on prior MRI
Equivocal prior Ultrasound for renal artery stenosis
Prior endarterectomy for TIA
hypercholesterolemia on statin therapy
How does an internist think through these problems? How does the acute problems relate to the known, chronic problems? Well physicians build a differential diagnosis based on all the information obtained. Our ability to build a differential diagnosis is directly dependent on the strength of our training, number of cases seen in our lifetime and the variety of clinical presentations for common and uncommon diseases. Patients rarely presents like a text book.
The building of the differential diagnosis is why we went to medical school and residency and is why an extender will never take over primary care
In this patient I developed the following differential diagnosis:
Adrenal Insufficiency.
Hypothyroidism
B12 Deficiency
Giant Cell Arteritis
Hypertensive crises
TIA
Volume depletion
Renal Artery Stenosis
Amyloidosis
The basis for my differential is as follows:
Adrenal insufficiency: Some of the hallmark complaints are dizzy, low energy, unsteady, abdominal pain. She had high normal potassium levels and low normal sodium levels. And she had high normal eosinophils on her peripheral smear. She also has an empty sella on her MRI, of unclear etiology. So how do I either confirm or exclude the diagnosis? I order a cosyntropin stimulation test where in I draw a random cortisol level, give here a hormone to stimulate her adrenal glands and then check 30 and 60 minute cortisol levels.
Hypothyroidism: She is on thyroid pills. Hypothyroid can do a lot of funny things. So it's always in the differential of just about everything. However, it is also in the differential of macrocytosis, which itself has a fairly limited differential (hypothyroidism, B12 deficiency, liver disease, bone marrow disease, usually myelodysplastic syndrome or other leukemic disorders)
B12 deficiency: Her level 6 months ago was low normal. B12 is an important vitamin necessary for nerve function. It is very common for elderly people to bet deficient. A low B12 can cause neurological changes, mental status changes, neuropathy, weakness and is in the differential of macrocytic anemia.
Giant Cell Arteritis/Temporal Arteritis: This is somewhat of an emergency. Failure to treat can cause permanent blindness. It is a vasculitis where in inflammation of the blood vessels can cause intermittent vision loss, jaw claudication, headaches. It is on a spectrum of disease with Polymyalgia Rheumatica (PMR) that usually presents in old people with bilateral shoulder pains. In my patient, she had some non descript complaints along all these lines and I felt warranted to check her ESR (erythrocyte sedimentation rate) for any signs of systemic inflammation. While not necessary to make the diagnosis, a sed rate over 100 in this clinical setting is almost diagnostic and would warrant immediate treatment with high dose steroids.
Hypertensive Crisis: This is a condition where in very high blood pressures can cause a multitude of complaints. Usually present in the form of delirium, headache, asymmetric focal neurological deficits (TIA type complaints), angina, acute systolic or diastolic heart failure. The very high blood pressure screws up your body. In my patients case, it is quite possible that her garbled speech was the result of a hypertensive TIA in the Broca's centers of the brain. However, the impressive orthostasis certainly wouldn't be consistent with this.
TIA. A garden variety TIA, either hypertension or thrombotic or embolic. Given her history of atherosclerotic vascular disease, her high blood pressure, her diastolic heart. I believe switching her from aspirin to Aggrenox is clinically warranted.
Volume Depletion: She may have nothing more than intravascular volume depletion. Common things are common. But it doesn't justify really high blood pressures.
Renal Artery Stenosis: It can explain really high blood pressures and renal insufficiency, but I'm hard pressed to explain, again, the orthostasis and her macrocytosis
Amyloidosis: No specific reason, except for a thickened heart.
Two of the rules of internal medicine are Common things are common And The most likely explanation is the right explanation.
In my patients situation, I don't yet have a unifying diagnosis to explain all the clinical abnormalities. On occasion, patients present with more than one unifying diagnosis, that breaks the rules we were taught.
This is how internal medicine and most docs in general are taught to think. It is not easy. It takes a lot of time. This patient had subjective complaints that spanned multiple organ systems:
Neurological
Musculoskeletal
Abdominal/GI
She also had objective abnormal findings from multiple organ systems
Kidney
Brain
Blood
Heart
The role of the internist as I have previously said is to put it all together into a unifying diagnosis.
This is how internists think.
This is not, in general, how specialists think
They are special because they know their organ well. Most specialists are so far out from their training from general medicine that asking a cardiologist to evaluate for polymyalgia rheumatica would raise eyebrows of confusion. It would be no where near their differential diagnosis.
This is internal medicine at its finest. It takes time. Lots of it. And to do a great job of managing a patient, not a disease or an organ takes a monstrous effort that demands respect. Unfortunately, this encounter, which took me over an hour to formulate after including my history, physical, review of old records, discussion with family and writing all my orders.
And this encounter at a high complexity visit will pay approximately $185 all inclusive by Medicare for over one hour of complex service.
Two screening colonscopies done in a gastroenterologist's office in an hours time will pay $400, plus facility fees. More if biopsy or polyp removals are done.
So we have an incredibly important role of primary care being decimated by the high cost of school loans, and the opportunity cost of entering other much more lucrative fields of medicine, or no medicine at all.
What we have left are specialists in their organ, but who have neither the ability nor the desire to evaluate the patient as a whole and develop a differential diagnosis that spans across all organ systems.
I don't yet know what the clinical diagnosis(s) will be in this patient. Time will tell.
This Is What I Do For A Living
And this is why your survival depends on primary care survival.
just out of curiosity, why would you ask a cardiologist to evaluate pmr? it is insulting when you say the diagnoses are not in the differential. disagree. they may not know how best to evaluate or treat it anymore, but they should still think about it, if it is appropriate.
ReplyDeletewhy not just admit all the patients to all hospitals everywhere? i'm sure the specialists would love to serve as consultants rather than primary admitters.
win-win?
Happy....
ReplyDeleteright on target as usual.
Thanks for the link!
Jordan
Fascinating post - reads like an episode of "House", minus the bizarre interactions with a hospital administrator. Please post again with the diagnosis.
ReplyDeleteGood post. Complicated patients int he hospital often get managed by a patchwork quilt of specialists, each managing his/her respective organ system. Renal for the kidney/electrolyte abnormalities, ID for fever, surgeon for the abdominal pain, cardiologist for the chronic AFib. The internist often doesn't get too involved in decision making, deferring to the specialists. So what happens is you lack a "captain of the ship". This fragmentary medical care, I think, leads to more errors and missed diagnoses because it's harder to notice overlapping patterns and diagnostic relationships when you're focused solely on say the kidney, or a blood culture from three days ago. The internist, instead of taking a back seat, maybe should be more aggressive in managing these complicated patients. Consults are fine; ultimately, however, final decision making ought to reside in one person's hands.
ReplyDeleteExcellent post that describes fully the thought process,necessary curiosity and expertise of an Internist. Your last sentence says it all. "Your survival depends on primary care survival." It seems the only ones acknowledging the benefits to society of primary care internal medicine are us. Despite the looming demise...nothing has changed in payment, recognition or training.
ReplyDeleteI'm not in medicine but read a lot of medical blogs as I find them very interesting. I could never do your job as I don't have the patience for this level of analysis. I imagine the population of people well suited to this type of work is rather small as a percentage of the U.S. population. That combined with the relatively low compensation for primary care convinces me that there is a crisis in our system in terms of future availability of primary care doctors.
ReplyDeletewhat was the final diagnosis?
ReplyDeleteI"m on vacation. I'll find out next week!, but I'll let you know
ReplyDeleteI love your blog but I just starting laughing out loud reading your last comment. Internists are God's special people. As an ER doc if I can't figure out the answer in a few hours I give up.
ReplyDeleteI love your blog but I just starting laughing out loud reading your last comment. Internists are God's special people. As an ER doc if I can't figure out the answer in a few hours I give up.
ReplyDeletei only wish the hospitalists I deal with were so concerned. Their #1 priority is to consult every specialist related to a positive response on the ROS.
ReplyDeletePlease reveal your diagnosis. This is my 2nd week in IM rotation as an M3 and am mystified by pt/older male veteran with multiple medical problems and orthostasis that has been investigated by 4 different VA's in 5 years. Since the comorbid bloody stool which the patient had on admission 5 days ago has mostly resolved, my team is ready to discharge. We are labeling the orthostasis as a more or less expected consequence of mildly uncontrolled DM. Even though the pt will be discharged tomorrow I keep looking back/thinking back to his old notes: the multi-factorialness of his case seems so unexplored and I am pondering it at stoplights and the supermarket. Please tell us the outcome of your case.
ReplyDelete