Blog | Monday, March 4, 2013

Did I have a diagnostic epiphany?

For the past two days, one patient's diagnosis has obsessed me. As the intern presented the patient's story, something did not make sense. We looked at the images and studied the labs. We went to the bedside, took a history and repeated the physical exam. We knew that the working diagnosis was wrong, but we floundered.

At our hospital we have an iPad app that allows us to review labs and orders from home. I kept on looking at the labs searching for a clue.

We ordered a test, and the results became available last night. I looked at the results, but they did not sink in. I actually awoke in the middle of the night, and began thinking about this patient. I rehashed the story in my mind. I reviewed the labs again.

Suddenly a light bulb turned on. The "fog of war" lifted. A new hypothesis emerged. I spent time checking on my assumptions through the Internet.

This morning, after a couple more hours of sleep, I reviewed the labs once again, and found a couple more clues that I had missed.

As Agatha Christie, said in Death on the Nile, "It often seems to me that's all detective work is, wiping out your false starts and beginning again. Yes, it is very true, that. And it is just what some people will not do. They conceive a certain theory, and everything has to fit into that theory. If one little fact will not fit it, they throw it aside. But it is always the facts that will not fit in that are significant."

I hope that I am correct. The diagnosis is treatable. We should be able to help our patient.

The diagnostic process, while often instantaneous, can be prolonged. I write this post to share my thoughts prior to confirming the diagnosis. I hope that some readers will relate to this obsession that I cannot shed. Getting to this diagnosis (and many) relates more to persistence than brilliance. At no time during this process can we (the housestaff team and I) be accused of brilliance. Rather we keep slogging away, reviewing our data, questioning ourselves and persisting.

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 Associate Dean for the Huntsville Regional Medical Campus of UASOM. He also serves as a frequent ward attending at the Birmingham VA Hospital. This post originally appeared at his blog, db's Medical Rants.