Posts Tagged ‘nosology’

Taking the pulse to get through the denial

November 19, 2012

How do we know what we know,

In a patient denying it’s so?

A two-week-old start

For a pain from the heart

Was part of a tale of woe.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

A doctor has to listen as carefully to what the patient says as to what the patient doesn’t say.  I don’t think any of the standardized tests given to doctors measure the ability of a physician to detect deception and denial in the history given, nor how to sneak through the web of drama and irony to get through to the truth.

I nodded while I listened to a patient talking about symptoms identical to the last three visits.  Taking full responsibility for the ruination of a perfectly good set of lungs, the patient seemed to me a little too cheerful.  In the middle of a digression I reached out my hand to the patient’s, and feeling the pulse, waited till the smile faded a little and I could speak without interrupting. 

“I think you had crushing chest pain for hours, going up into both sides of your jaw, with sweating and nausea and shortness of breath even worse than usual, about two weeks ago, and it went away and ever since then you’ve felt just terrible.”

The gaze dropped and the sigh came through over the gentle hiss of the oxygen as the smile faded. “That’s about the size of it.”  I kept my index and middle fingers on the pulse and I waited.  “You don’t think it was a heart attack, do you?”

“I do,” I said. 

“Well, I guess I thought so to, or else I wouldn’t have made the appointment.  I just didn’t want my daughter to know, she’d have made me go to the hospital.”  We looked at each other and burst into laughter.  “That sounded pretty stupid,” the patient said.

“There’s a difference between fear of hospitals and stupidity,” I said.  “We need an electrocardiogram and a chest x-ray.”

After the lab studies confirmed what I already knew, I started into the part of the interview known as the Review of Systems.  “Any depression?” I asked.

A shake of the head, followed by, “No, no, not at all.  Not anything worse than usual.”  I reached my hand out again and the patient’s forced smile fled.  “Yeah, I guess I’ve been pretty depressed ever since.”  I nodded and we laughed again and then we laughed because we were laughing about depression.

The patient gave me permission to write a good deal more information than I have, about a visit stretching over an hour and a half, and touching on issues of intergenerational conflict, ripples of familial dysfunction getting worse and getting better in children and grandchildren and great-grandchildren, nosology, intellectual honesty, freedom of choice, and game theory. 

I ended up giving bad news and reassuring at the same time.  I arranged for proper follow-up and explained new medications. 

Of course when that patient left I went on to the next one and apologized for running late.

 

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Blizzards, syphilis, and nosology (the study of how we know what we know)

December 12, 2010

How do we know what we know?

If the test says ‘yes’, is it so?

     False positive rates

     In some disease states

Can lead to some terrible woe.

 

Cold came to Iowa overnight, strong enough to generate national news.

I arrived to make hospital rounds yesterday, and talked with the doc on call.  We eyed the weather reports and I took over call early, allowing the other physician to get home before a blizzard hit.

Patients like to stay sheltered when the wind chill goes to double negative digits, only the much sicker come in. The forecast called for 40-50 mile per hour winds, heavy snow, and temps around zero.  After supper I packed an overnight bag and returned the half-mile to the hospital.      

I didn’t have to stay the night at the hospital; I could have waited to get called.  I wasn’t sure the blizzard would really happen, but I didn’t want to face whiteout conditions trying to get to the ER. 

I drifted to the nurses’ station first.  With a census of three, the staff outnumbered the patients.  We chatted about the cold, deer season, and the patients.  I got some surprise lab results.

Mostly we get information from laboratory tests to confirm what we think is wrong; rarely (not never) do we generate as much decision making from x-rays or blood and urine tests as we do from talking to the patient.  Sometimes the patient can’t talk, can’t remember, or won’t tell the truth.  In those cases lab and x-ray add heavily to the diagnosis.

Yes, I ask for tests “just to make sure,” and sometimes when the case perplexes me I’ll order a large number of lab tests.  Ninety percent of those results come back as expected.  Ten percent of the time they don’t.

I finished residency thirty-two years ago, when syphilis used to be called the ‘Great Pretender’ because it could mimic any other disease.  As med students we learned to order certain labs as a matter of course, especially the serologic test for syphilis, aka STS, Wasserman test, VDRL, or RPR.  Later we learned to order the confirmatory test, the free treponemal antigen (FTA) or Treponema palladium plasma antigen (TPPA). 

As rates of syphilis fell, the disease changed and enthusiasm for testing waned.  In medical school, we were taught that the infection always started with a sore.  By 1990 the sore happened occasionally.  Now we almost never find one.

I still test for syphilis despite low rates.  Since 1982 on five occasions the test came back positive and surprised us all; on one occasion, years ago in another place, the positive result startled me but not the patient.  I came away with a history lesson in riverboats and an appreciation for Midwestern life in the thirties. 

The diagnosis remains a problem in nosology.  The first test has false positives (as in Lyme disease) and false negatives (late in the illness), the second test has no false positives but cannot distinguish active disease from prior infection.  In the end, there is no substitute for clinical judgement.