March 20, 2003

     Not all of us have the privilege of technology in our medical practice. More often than not, the most important tool we have in our disposal is our clinical acumen, which is one thing we always carry around whenever the chance encounter with a patient occurs. We cannot always rely, or even simply find, a hi-tech lab or state of the art radiology department at our disposal whenever we need them. So what do we do? Just practice medicine the old-fashioned way: using our brain.

     Use our brain?? Yes, once in awhile, we do need to use that 1,500 ml mush inside that hollow cranium. My medical professor once taught me that the most important aspect of diagnosis is the history and physical examination, not some test or x-ray. Ask any experienced doc, and you will find that this is true, more often by chance rather than choice. So we need to brush up on doing a good, efficient, and directed “H & P” always.

     Here are a few true examples of oversights I have seen due to poor H & P’s:

     A 75-year-old woman came in for a headache. The family noted that she had been becoming more demented over a few weeks. She is also currently having a cold and was therefore diagnosed with “sinusitis” after a 5-minute office visit. It was never explored further that she had a history of paroxysmal atrial fibrillation, and was taking warfarin. Further, the doctor neglected to see that she had fall, and a tiny bruise in her forehead. If he only used a penlight, he would have seen that she had one pupil smaller than the other. Two days later, she returns unresponsive and dies despite resuscitation. Autopsy revealed a subdural hematoma.

     A 6-year-old boy kept having a runny nose, despite multiple courses of antibiotics and decongestants. The kid likes playing with his food but now he is very agitated and will not permit a thorough exam. The “PGI” failed to notice that the drainage is mostly from one nostril, and the drainage is foul smelling and bloody at times. Eventually ENT got involved and found a dozen peanuts stuck in his nasal cavity, some of which were actually visible externally. The PGI was too lazy to carry around his otoscope set; otherwise, he would have seen the nuts.

     A 45-year-old man was admitted from the ER with chest pain. He had no risk factors for coronary artery disease but the sleepy intern can’t think of anything else but a heart attack. EKG and cardiac enzymes were normal, and he now scheduled him for transfer for a VQ scan to rule out pulmonary embolism. En route, he coded. During CPR, the nurse noted that there was no pulse in one arm and foot. After death, a dissecting aortic aneurysm was found, which may have been diagnosed if someone felt his pulses and paid attention to his atypical presentation.

     An 18-year-old teenager was complaining of hypogastric pain, nausea and painful urination. The “Sub-I” dutifully did a urine dipstick and found pyuria, proudly diagnosing UTI. Without further ado, she prescribed Ciprofloxacin. Eight months later, while in her OB rotation, she sees the same woman in labor and she delivers a baby with limb abnormalities. The Sub-I would have avoided a lawsuit if she asked for the LMP and did a pregnancy test.

     A 48-year-old alcoholic man recently had pneumonia and 2 weeks of antibiotics. He now presents with fever, abdominal pain and diarrhea. Liver and pancreatic enzymes were mildly abnormal, and an ultrasound showed a normal sized gallbladder and CBD but with gallstones. He undergoes cholecystectomy and gets 3 antibiotics. Two days post-op, his symptoms are worse and his WBC count is 45,000. A CT scan showed ileus and fluid around the biliary tree, and was read as “possible bile leak”. He is rushed to the OR and explored, finding everything normal but mild colonic edema. Nobody bothered to check a Clostridium difficile stool test, or added Metronidazole to the regimen. He simply had C. difficile colitis.

     A 30-year-old man came in with recent “stomach flu” and a “thick tongue sensation”. Nothing seemed to cure it but at the second office visit, he started squirming, twisting his arms involuntarily and biting his tongue. His temperature was 42 C. He is brought to the ER and given diazepam and phenytoin. When his medicine bottles were finally opened days later, he has been taking 10 mg of metoclopramide every 2 to 4 hours for the past 2 weeks. No medication history was found in the intern’s notes.

     Some of the major lessons we can glean from these are the following:

1. Always get a complete history; rule in the obvious first, then rule out the most life threatening. If nothing makes a lot of sense, start thinking of the rare entities. Especially if you are pressed for time, direct your history taking with a balance of closed and open-ended questions.
2. Using the information from the interview, perform a thorough physical exam in accordance with your suspected diagnosis. Examine first the anatomic spot or organ system most likely involved, but do not miss clues from distant sites. If you are in an emergency do both the history and physical simultaneously with emphasis on the chief complaint.
3. If the patient is unable to give a decent history, always seek out other possible historians like witnesses, family, and friends. If this cannot be done right away, address the emergency first then always find a historian to make sure you are making the right diagnosis.
4. After the H & P, order first the fastest and simplest test to rule in or out your suspected diagnosis, with careful thought whether it will diagnose the most serious conditions you are suspecting. After the emergency is resolved, consider each test if it will alter your management of the case.
5. Some often missed and very important information or actions which could cost a life and bring in a lawsuit are:

1. Is the patient pregnant or not and is it safe for her to get the drug or treatment being planned?
2. What medicines is the patient taking and does it have anything to do with the current problem?
3. What possible dangerous drug interactions may occur with the drugs being prescribed or administered?
4. Do the risks outweigh the benefits of the test or treatment?
5. Is there informed consent before the procedure?
6. Is it the right drug at the right dose given at the right speed at the right schedule through the right route for the right patient?
7. Is it the correct surgery on the correct patient, on the correct side or part of the body?
8. Is the incision, suture or ligation on the right spot, organ or structure and not inadvertently extending over to a non involved structure?

     We can go on and on…..There are just so many ways to commit mistakes that lawyers can have a field day if they pore deep enough. But it all starts with a good history and physical, and paying attention to the clinical clues that may just be right under your nose.

Comments regarding this week's column are welcome. Please fill up the fields below and click Send to Author.

     The author's e-mail address is at docdan1@pol.net.

     Views expressed on this column and any other by-lined articles on this site are the authors' own and do not necessarily reflect the views of the organization or its members. For comments, please e-mail the author.