Thursday, August 7, 2014

Physical Examination Saves Lives And Money

I just attended an M&M done by one of our chief residents at our hospital and it raised a few issues that I wanted to write about.

A 50 year old man, originally from Ethiopia, sought medical care for progressive weakness for the past three months or so, so severe that he was unable to do his job of working as a cab driver. He had emigrated to the US about 15 years ago and his chief complaint was taken to mean "dyspnea on exertion" which lead to admission under a cardiomyopathy service- his then documented physical exam was positive for abdominal distension without any other cardiac, lung or peripheral extremity findings. Lab tests of note BNP was 35, hemoglobin was 10, renal and liver function tests were within normal limits.

He had a cardiac echo, right heart catheterization- which were all normal and was sent home for follow up with Neurology for "weakness". When he came back for his Neurology Clinic appointment, it was noted that he had abdominal distension and striae and they referred him to Endocrinology for "further work-up" of Cushing's syndrome.

We failed this man in many ways- his words were mauled into a "good fit" for a cardiac story which was milked with all sorts of testing without any Bayesian thoughts. The clinicians that cared for him seemed not to have really seen him- it took an inpatient stay and an astute neurologist to consider the diagnosis that brought him to the hospital. This is a disease that is ripe for questions during USMLE steps, shelf examinations, pimping sessions during rounds and yet this man got a gazillion tests- cardiac catheterization, inpatient lung functions tests, CT chest, Ultrasound of the abdomen and many, many blood tests before someone really looked at him.

As I walked out of the conference room, I chatted with my colleague saying that a good internist would have caught that, don't you think? He replied, "I'm not sure- a good internist would have completed all the clinical reminders,for sure."

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