Blog | Thursday, December 22, 2016

With diagnosis, the adjectives are just as important as the nouns


You present a patient with a past medical history of chronic kidney disease, heart failure and type 2 diabetes. I hear 3 nouns, but I really do not know much about the past medical history.

Cardiologists and coders demand that we further define the heart failure: left or right, if left systolic dysfunction or preserved ejection fraction. Is there valvular disease, or restrictive cardiomyopathy. The nouns do not tell the story.

With type 2 diabetes we need to know how long and what complications. With chronic obstructive pulmonary disease we should know how severe the obstruction and whether they need home oxygen. Is it mostly emphysema or chronic bronchitis?

This article The CKD Classification System in the Precision Medicine Era from the Clinical Journal of the American Society of Nephrology speaks loudly to this problem:

“Chronic diseases of the kidney range from rare inherited disorders, such as Fabry disease, to more common acquired entities, such as diabetic kidney disease. Despite the myriad clinical phenotypes and histopathologic subtypes, even within, for example, diabetic kidney disease, this diverse collective is viewed similarly when estimates of glomerular filtration align. Contrast this approach with that of multiple myeloma, a diagnosis that prompts routine cytogenetic studies, such as fluorescent in situ hybridization, to guide additional diagnostics, therapeutics, and research. Classifying kidney diseases on the basis of eGFR further ignores the complexities of renal function.”

We should demand more precision in our history taking and reporting. Understanding the adjectives helps us better address the patient's complaints and diagnosis. We should not simplify our diagnosis list.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.