Monday, December 9, 2013
Presenting on a consult service: Rule number four
A while back, I posted three “rules” of presenting on a consult service. I’d now like to add a fourth rule.
Rule Number 4: In patients with chronic disorders, consider more than simply a “disease flare” in your differential diagnosis.
This rule follows up on Rule Number 3. The rule is most relevant to patients with underlying chronic disorders (e.g., inflammatory bowel disease, emphysema, ischemic cardiomyopathy) and is important for fleshing out a broad framework for a differential diagnosis.
After you have gone through a detailed presentation of a patient with a chronic disorder, the path of least resistance when a patient presents with similar signs, symptoms, and findings, is to diagnose a “disease flare.” However this knee-jerk reaction excludes a number of other broad options that may be going on.
Here is the framework I suggest in considering your differential diagnosis in a patient with a chronic underlying disorder. The presentation could be caused by:
1. the disease,
2. a complication of the disease,
3. a complication of the treatment of the disease, and/or
4. a completely unrelated disease.
In virtually any patient, this general schema can be helpful to make sure that you do not anchor your diagnostic possibilities on the chronic disorder.
As an illustration of how I use the framework on teaching rounds, I’ll describe a typical (made-up) case we might see on the gastroenterological consult service, a 25-year old man with Crohn’s disease and a possible flare. He was diagnosed 6 months prior with inflammatory ileocecal Crohn’s disease after presenting with right lower quadrant abdominal pain and watery diarrhea. The colonoscopy at the time revealed severe inflammation in the cecum and terminal ileum. He has been treated with steroids and infliximab, and was brought into remission within 3 months. Now, he presents with 3 days of acute watery diarrhea and recurrent abdominal pain. Without giving any more details, here is how I might break down my thinking:
1. The disease: Sure, it is easy to say that this is a “Crohn’s flare,” but then you’d have to ask yourself, “Why is the disease flaring?” Could the medications no longer be working? Has the patient been adhering the treatment regimen? Are the medication dosages too low? Nevertheless, this is an easy place to stop unless you consider the next 3 broad possibilities.
2. A complication of the disease: Crohn disease can cause at least 2 complications that can lead to similar presentations: fistulae and strictures. Of course, you could argue that these are the disease itself, but I would refute the argument because the treatment of these complications can be different from treating the underlying inflammatory process itself.
3. A complication of the treatment of the disease: As much as physicians don’t like to admit it, our therapies can definitely play a role in our patients’ worsening. Surgeons are quite attuned to looking for complications of their surgeries while their patients are recovering in the hospital, but medical therapies also have complications that should be considered, especially in the outpatient setting. In this case, the patient is on immunosuppressive agents. Could the treatment have led to an infectious disease, such as cytomegalovirus colitis?
4. A completely unrelated disease: Importantly, this element, sometimes known as ”true, true, and unrelated,” is how we are taught to think when we are creating differential diagnoses in medical school and residency training, but can often get neglected in the presence of a chronic disorder. Does he have a young child in preschool, who could have contracted a Rotavirus infection and transmitted it to your patient? Could the patient have taken an antibiotic for a sinus infection and developed Clostridium difficile colitis? Here the differential diagnosis can be quite broad, but should certainly not be overlooked when the patient has a chronic disorder.
Acknowledgement: Arvey I. Rogers, MD, FACP, my first clinical mentor, deserves the credit for teaching me this framework. He is a wonderful clinician, a thoughtful educator, and a gem of a person.
Ryan Madanick, MD, is an ACP Member, a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain. This post originally appeared at his blog, Gut Check.
Contact ACP Internist
Send comments to ACP Internist staff at firstname.lastname@example.org.
- Why does computerized physician order entry take s...
- The long arm of medical ethics
- A step forward for artificial limbs
- QD: News Every Day--Less than 1% of anesthesiology...
- What the new statins guidelines say, and should we...
- Grains of truth
- Finally! Physician performance measurement questio...
- Movie takes on AIDS, peer patients, and not taking...
- Tweeting back to the future
- Antibiotic resistance is a global problem
Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.
And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
Controversies in Hospital
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.
Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.
David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.
Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.
Reflections of a Grady
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.
The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.
Technology in (Medical)
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.
Peter A. Lipson,
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.
Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.
World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.
Other blogs of note:
American Journal of
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.
The Public Library of Science's open access materials include a blog.
One of the most popular anonymous blogs written by an emergency room physician.