Archive for the 'Progress Notes' Category

The Art of Diagnosis: Go With Your Gut, Dig Deeper, Step Back or Start Over

Nelson Malloy had infrequent but bothersome spells when he felt drained for half a day or more. He just couldn’t put his finger on exactly how he felt. Neither he nor I knew in the beginning what his symptoms were all about. The usual fatigue related bloodwork came back normal. His pulse in the office was exactly 50. On a hunch, I suggested tapering his lowest strength tablet of metoprolol tartrate down to half a tablet twice a day and that seemed to have solved his problem. The medication had been started after a questionable non-ST elevation myocardial infarction a few years earlier. Encouraged, he stopped it altogether and instead ended up with two hours of palpitations, triggered by a stressful event, with a heart rate upwards of 150. I advised him to resume the half tablet regimen. He may need more testing if he gets palpitations again.

Ben Chasse stumped me before with his drowsiness and his various neck and head pains. Was he just hypoglycemic with a herniated disc in his neck and an unrelated ordinary cellulitis, or something more exotic? Now, after neck surgery and off most of his diabetes medications, could his reoccurring spells of fatigue and shortness of breath be related to suddenly high blood sugars? After all, he was not anemic, his chest CT, echocardiogram and stress test were all normal and his peak flow was the same as mine. Time will tell, now that he is starting to take care of his diabetes again.

Sometimes the broader view holds the answer. It helps to ask “what else is going on” or to do a review of systems that includes things we might not think have anything to do with the chief complaint. 

Wanda Starks, years ago, puzzled me with her recurrent episodes of mild confusion, nausea and ever so slight headaches. She seemed to have a migraine equivalent, but it took ten years of infrequent by-the-way mentions before I realized what ailed her.

As I wrote about Wanda’s case back in 2008:

When you get stuck in a diagnostic dilemma you have two ways of approaching the problem. You can dig deeper and meticulously go over all the tests that have been done so far, looking for anything that could have been missed. You can also do the opposite, step back, clear your mind and listen to the patient’s story all over again. It is a little bit like those pictures in psychology class; the more you stare at them, the less likely you are to see the hidden image. Sometimes if you squint, you can see it right away.

And in 2009, in a story about Mrs. Jarvis’ spells of nausea, I also wrote about starting over:

“I am stuck,” I said. She sighed as I continued: “I must be missing something in your story.” Then, in a moment of inspiration, I got up from my stool and walked over to the exam room door as she followed my movements with suspicion and disbelief in her eyes.

With one hand on the doorknob I turned toward her and explained what I was doing:

“Pretend I’m an amnesiac or that you never met me or told me what you are feeling. I need to hear your story again from the beginning and without interruptions.”

The punch line in that story was:

Five minutes later, without asking a single further question, I knew what to do.

There are many ways to get unstuck. We must be prepared to use all of them.

When I Escalated His GERD Treatment, My Patient Got Worse. Now I Know Why

Pierre Patenaud had a long history of dyspepsia with fair control on 20 mg of omeprazole. A few months ago, he started getting worse. My first response was to check for changes in his lifestyle and increase his dose to 40 mg. When that didn’t work, I added famotidine 40 mg twice a day. He felt worse and even developed hoarseness. I prescribed sucralfate before meals and at bedtime and made a referral to one of our general surgeons for an upper endoscopy.

The other day I got a call from the surgeon.

“Mr Patenaud’s endoscopy looked atrophic and I just got a call from the pathologist. The biopsies were negative for helicopabter pylori, but he’s got giardia in his stomach.”

“I’ve never heard of that”, I said, “and he hasn’t had any lower GI symptoms.”

My literature search yielded mostly old articles, like an Italian one from 1992 linking it to helicobacter pylori, a 1994 piece in the BMJ linking it to achlorhydria (which may be why Mr. Patenaud got worse with more acid suppression) and bile reflux (bile is alkaline). The most recent piece I read was from 2009 by the WHO, reporting Egyptian data on helicobacter pylori and giardia, which often coexist as they are transmitted in the same fashion between individuals.

The lesson here is: Not all dyspepsia is due to acid excess or reflux, or even bile reflux in and of itself. And the ones that are neither of those aren’t necessarily irritable bowel related “nonulcer dyspepsia” – a strong case for scoping and biopsying difficult dyspepsia.

Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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