Friday, June 27, 2008

I diagnosed impetigo today...

I diagnosed the crap out of it!

What happens is, as the student I'm there to collect the info. I've been with an Internal Med doctor with a thriving practice and a ton of patients. Almost all of them have some kind of chronic issue going on, and even when that's not the reason for the visit, it's important to know how things are going. So I talk a lot about diabetes, and heart disease, and medications. I spend a lot of time writing down the ten different meds* the patient is on, the dose, what they've changed recently, and what they don't like to take.

I also do a review of systems, which is where I ask a ton of questions about all kinds of stuff that isn't what the patient came in for. The detail and length of this list increases proportionally with the length of time since the last visit, too. And since I don't want to take all day with this, it's a good thing that the actual physical exam portion of my standard history-and-physical can be made pretty snappy.

I do my writing, which has also become much faster, and then I go speak with the attending physician. We'll talk for a moment, maybe while walking, and then he'll open the door to the exam room, say hi to the patient, and do what I just did, except so much more quickly and efficiently it's kind of embarrassing.

Now, true, part of the reason he can do that is he already knows this patient well. In a lot of cases, they've been seeing this same doc for years. Another reason he can be speedy is that I just did the time-consuming stuff, and I've just distilled down the most important 30 seconds of the 20 minutes it took me to find it. But also, he's been doing this a long time and I just started.

So. I've filled in half the page or more, with my block-printing marching a couple dozen rows down. Then he'll scrawl "IMP" (for "clinical impression," which is like diagnosis except that it doesn't necessarily have to be something that is truly, technically a diagnosis), and then put in a word or two the answer to the question I started asking back at the beginning of my interview: "what is it that we can help you with today?" The MD then scrawls "PLAN" and lists the tests, the meds, the treatments that will be needed to get the patient to the next step, so we can start all over in a week or a month, or whenever the next visit should happen.

I like it this way. My own "IMP" and "PLAN" are part of the conversation we have outside, of course. I'm not just a note-taker or an inquisitor -- although the key to a good diagnosis is asking the right questions (and hopefully not too many that turn out to be dead ends). You've seen "House." You know the score. But my impression doesn't go in the chart, because that's not the way we do it here. And that's cool with me.

Except when I'm really, really sure. There have been a few things that I've felt so confident that I would have been just shocked if I was wrong about them. I sent a woman to the ER because right in the middle of telling me about the vertigo with a horrible headache that comprised the attacks she'd started having, she had one... and there was a little bit of a seizure too. The doc agreed that she needed to get down there, so we whisked her away. We admitted her, and it turns out she had a nasty infection in the bones of her skull.

Today was a case that kind of jumped right out of the mental version of my dermatology notes. So I wrote "IMP: Impetigo" before I went to fetch the doctor. He looked at the patient, said, "yep, I agree," and did the rest of his scribbling.

Maybe it's a Stockholm Syndrome kind of thing, with the hours and the intensity, but it's really nice to get props of this nature.

* seriously, sometimes it's 12 or more. Rarely it's only one or two, and I'm like, "huh." And then there are the patients younger than 45 or so who take no meds at all -- they're the minority, and I don't tend to see them twice within my six-week term, ya know?


Heather said...

"...she had a nasty infection in the bones of her skull."

Wow, that is a totally new one to me. *shudder*

Glad things are going well thus far -


(back to lurking......)

Febrifuge said...

Mastoiditis. It's a bummer. A couple of days of IV antibiotics starts to chase it away, though.

Rabrab said...

Feb, this comment is completely irrelevant to the post I'm attaching it to, but, I need to tell you this:

Two of your previous posts were immensely important to me and to my husband today.

The first was the one where you quoted one of your teacher/mentors: "Fill in the f@#$in' blank!" Answer the question they need answered, even if it's not the one they asked.

The second was the one where you explained why it's OK for the ER folks to know what it's *not* and not so much what it *is*.

Because of those two posts, when I wheeled my husband into the ER wheezing and gasping for breath at 11:00 am, I knew that the answer they needed was "Breathing distress, worsening since about 4:00 am today; he's used his nebulizer four times already, with Duo-Neb." and not some long winded explanation of what was going on.

And I knew enough to reassure him that the fact the ER doc said "I don't know for sure what it is, but..." didn't mean she had failed, but rather that she had succeeded.

Thank you.