Some time ago I issued a naturopath challenge in which I invited naturopaths to analyse a typical primary care problem. Today, I’d like to issue a broader challenge.
With health care reform in the works, it would be wise to look north (or in my case, south) to our Canadian neighbo(u)rs, but not for the reason you think. Assuming we are able to extend health insurance coverage to millions of more Americans, we will need primary care practitioners (PCPs) who can care for these new medical consumers. In Canada, legislation to deal with a shortage of PCPs by giving modest new powers to other practitioners was hijacked. Naturopaths, a cult of “alternative” healers, managed to sneak in a provision to give them prescribing powers. As we deal with our own shortage of PCPs here in the States, we need to maintain our vigilance.
In the US, most PCPs are either internists, pediatricians, or family physicians. Each of these types of practitioner spends three to four years after medical school studying their specialty. This time is not frivolously spent; after four years of medical school, there’s still a lot to learn. Naturopaths do not participate in medical residencies and are approved by their own regulating body to practice “primary care” after four years of naturopathic school. But medicine is rather complicated, and biology doesn’t really care about ideology. Wishing that your medical beliefs were true does not make them so.
So here’s a new challenge. Anyone out there who claims to be a PCP but is not a member of one of the traditional specialties must be able to handle this sort of situation. Naturopaths, TCMs, functional medicine practioners, and whomever else considers themselves to be a non-traditional PCP should feel free to respond here.
Mr. H is a 60 year old male with a history of diabetes and coronary artery disease. He comes to see you today complaining of a cough. The cough has lasted for about eight weeks. He reports that the cough is usually dry, but occasionally productive. It is sometimes worse at night, but not always. He does not cough enough to cause vomiting. He denies any fevers, chills, or weight loss. He denies chest pain, but reports shortness of breath on exertion from time to time.
He has a 35 pack-year history of cigarette smoking and quit six months ago after a cardiac catheterization.
On initial exam, he is thin but not cachectic, and in no distress. He is coughing from time to time and his voice is normal. His breath sounds are faint bilaterally as are his heart tones. He has 1+ lower extremity edema bilaterally.
Given the limited history exam, what is the differential diagnosis and what should be the initial approach?
Remember, please allow alternative practitioners to answer first.
I’m thinking I’m not getting as many altmed readers as I used to, so I’m going to open up the floor to anyone who wants to leave a differential diagnosis. I’d like this to serve as an additional example of how real doctors think.