White Coat Underground

Primary Care Challenge, Part II

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.

Addendum

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.

Comments

  1. #1 Dianne
    December 8, 2009

    Do we get to ask any further questions? You’ve left out a couple of points that would, IMHO, be helpful. (Not that I’m really qualified to answer the post since I’m a specialist.)

  2. #2 PalMD
    December 8, 2009

    I presented the case with exactly the information i wanted to : )

  3. #3 Hildy
    December 9, 2009

    Are non-PCP residents/specialists permitted to answer?

  4. #4 PalMD
    December 9, 2009

    I’m gonna give everyone a stab at it like my usual morning report cases but only after some altmed folks get a chance.

  5. #5 Kahtarine
    December 9, 2009

    I was under the impression, in the last thread, that a lot of the naturopaths didn’t realize that medicine, to steal a phrase from Physioprof, is not a care bears fucking tea party.

    There was even one of them that said something to the effect of ‘whine whine but they have nowhere else to goooooo and medicine has faaaaailed them’.

    It’s better to give them nothing than give them something which has an unknown potential of hurting them; much of what naturopaths do, I bet, would get a real physician sued for malpractice. (Naturopaths aren’t doctors. I can’t respect a degree not based on facts.)

    I would never go to a physician who sought to appease more than to treat people with a solid understanding of how humans work (because, no matter what the condition, there is the same underlying biochemistry – sure, there are minor differences in all of us, but we share 99.5% of genes, if I remember correctly – human biochemical ‘types’? What crap!)

    I wasn’t surprised that many medical students performed better than the naturopaths; they’re learning real medicine.

  6. #6 DrWonderful
    December 9, 2009

    With such a limited history and exam, which is considered substandard by the way, I would first r/o DVT w/ doppler ultrasound and if negative consider Emphysema, CHF, Lung CA, etc and refer to PCP. How’d I do?

    I would hope you would not continue misinform your readers about the specific language in the health care refrom leigstion you and so many of your blogger cohorts are railing about. when discussing this type of thing, consider Chiropractic physicians as primary portal of entry docs, not replacements for primary care medicine. That is the specific language of the health care reform legislation that is pending. In order to increase availabilty of front line care the reform bills encourage the increase utilization of primary “contact” disciplines that are licensed to differentially diagnose.

    I am amazed that for such “skeptics” and “critical thinkers” just how biased and unobjective many of you are. You can pull out the “disasters” from alt med and objectively line up them next to the disasters from medicine and it all pretty much the looks the same, you know. Good quizz, though. Very good question.

  7. #7 VikingMoose
    December 9, 2009

    Thanks for engaging these exercises, Dr PalMD :)

    Very interesting reads. Of course, I’m not a health care professional, so I have no clue :)

    greetings from chicago to Michigan!

  8. #8 BD Palmer
    December 9, 2009

    …that are licensed to differentially diagnose.

    LOL.

    Yes, let’s send sick folks to a chiropractor who can then send them on to a PCP. That’ll save a lot of money.

  9. #9 BD Palmer
    December 9, 2009

    I can’t respect a degree not based on facts.

    Vitalism is a toxin for which there is no liver flush.

  10. #10 BD Palmer
    December 9, 2009

    With such a limited history and exam, which is considered substandard by the way…

    I have no idea what that snarky aside means, but I suspect it’s an evasion. Knowing stuff means getting to the point.

    If you have relevant questions regarding Mr. H’s history and exam, ask ‘em. Asking questions is part of “what would you do?”

  11. #11 PalMD
    December 9, 2009

    Claiming that this history and physical is insufficient is a ridiculous dodge. This is more than is often available, but less than we want. IOW, it’s typical. The process of developing a differential diagnosis means engaging your brain, and then asking for more info to help winnow down the options.

  12. #12 DrWonderful
    December 9, 2009

    BD- did you read Dianne’s comment? It is listed as #1 in this thread. You might want to go back and read it. Or did you simply immediately decide (in a biased and discriminatory way) that I was stupid because I’m a chiropractic physician? No further questions are allowed per the moderator.

    PS- (ssssh, btw you and I, if your name indicates that you are trying to conjure up an image one of the credited founders of chiropractic you may want to do more research there. They were DD Palmer or BJ Palmer. Not BD Palmer. But I am sure you already knew that. Not that I am big Palmer guy, but as a skeptic I assume you’d want to be exactly correct in everything you say and do so that you are totally above any critique. Just thinking of you bro.)

  13. #13 Shira
    December 9, 2009

    @ dr. wonderful: Whether the ‘disasters’ match up is irrelevant. Medicine abandons the disasters and produces a lot of useful treatments, whereas alt med holds onto the disastrous implausible and often harmful “treatments,” and does not produce useful results, much less the incredible successes of evidence-based medicine.

    I’m a patient and not a physician, but I’ve had that constellation of symptoms caused by something that’s really common, especially in older smokers (though in my case it’s due to a connective tissue disorder-hint hint!) and is easily treatable, that you left out of your differential.

  14. #14 DrWonderful
    December 9, 2009

    PalMD- This isn’t working out the way you hoped, huh? Who’s dodging? I answered the question you asked and every critique so far. I’m certanly not dodging.

    Anyway, thank you for taking me back to my third trimester of chiropractic school. My physical diagnosis instructor (a DC)and clinical pathology instructor (an MD) would agree with your lesson on DDx. But they also would support, as being a very good, my answer and the fact that the level of information you provided does not meet the standard of care with regards to a history or examination.

    Having read Dianne’s comment at #1, and then seeing your response that questions were now allowed, well, I decided not to ask for more information. However, what is striking is the tone you took with me as compared to Dianne. Why not scold her like you scolded the chiropracic physician? Are you biased and on a pre-determined mission to discriminate and discredit my profession? You do realize that is frowned upon in this country, don’t you?

    Anyway, what I think is obvious here is that I did a very good job answering your clincal question but you are completely unable (because it would bust the plan) and unwilling to give a chiropractor any credit even when they do well. So you are the one who dodged and went after somoething totally irrelevant like comment that information you gave is not adequate. Isn’t that true?

    The truth is the limited information you provided is below the standard required to make an accurate differential diagnosis. I only mentioned this so as to demonstrate that I understand what that threshold is and wa snot met as a critique of you (we all know how that goes *eyes roll*). As a result my comment is appropriate. Despite this I gave also gave an my best clincal judegment, based on said limited information. Would care to comment on how well I did in my answer or would you, sir, prefer to continue to be the one that dodges the fact that I did a very good job.

    You guys should considering organizing covert terror campaigns like billboards and buses with ads on them about chiropractors causing strokes because testing us clincially, and trying to deny the evidence that we perform very well, simply will not go your way. For the record, in 22 years of practice I have caught more strokes in progress prior to treatment(3) than I have been associated with (0).

    Also, it’s a shame what you are doing to chiropractors over there in Michigan. You should be embarrased. You do not get to take pot shots at me or my profession, sir, without being called out in public and challenged.

    So, tell us all…was it not excellent clinical judgement as a primary contact provider to consider a DVT? Tell us the truth. Did I do a good job? Can you say in public the chiropractic physician did a good job differentially diagnosing this situation and also made the appropriate clinical decision? Please do not be the one who dodges, here. A LOT (a whole lot) of people are watching this and your credibility is now completely at stake.

  15. #15 daedalus2u
    December 9, 2009

    I assume that because increasing nitric oxide is not yet mainstream medical treatment, that it constitutes “alternative” for the purposes of this test (although in no way, shape or form would I pretend to be a PCP).

    DrWonderful, if there isn’t enough information to go on, as a “professional” you are supposed to know that and get more information, what ever information you need, not simply guess.

    He does have low basal NO levels. However, raising someone’s NO level should only be done if there is nothing that would be made worse by higher NO levels (some types of cancer, maybe?). I would suspect pulmonary hypertension. CO is a NO mimetic, and smoking does cause pulmonary hypertension.

    Because the edema in the legs is bilateral, DVT is unlikely. I see DVT as a zebra. Similarly because the chest sounds are symmetrical I see lung cancer as a zebra too. He was catheterized for CAD. He might be on anticoagulants. If so, DVT is very remote.

    Did they put in a stent when he was catheterized? I would ask what meds he it taking for his CAD. ACE inhibitors sometimes have cough as a side effect. If he is taking an ACE inhibitor I would consider switching to something else, a diuretic maybe, probably not a beta blocker because that can mask low blood sugar symptoms in someone diabetic.

    The coughing might suggest a lung infection of long duration, not one that is self-limiting like a virus or rapidly progressing bacterial one. No fever, maybe TB. Ask about recent travel, exercise, stress, diet, diabetes control. If he is not taking an ACE inhibitor I would want a culture.

    He is diabetic, so I would check how well it is controlled via blood and urine tests. Do blood pressure, looked for clubbed fingers, check his color, check his arterial O2 saturation via finger thing, check the color of his extremities, check their temperature, ask him about foot care.

    I would order a chest x-ray to look for heart enlargement and get the ones from before and after his catheterization for comparison, looking for right or left ventricle enlargement.

    My suspicion is high blood pressure, some heart enlargement. He needs more NO, but the only recognized way is by eating green leafy vegetables which I would recommend and ask if he wanted a seasonal flu and H1N1 flu vaccination.

  16. #16 DrWonderful
    December 9, 2009

    Shira- you are correct. The comprehesive list of differentials probably is 20 items deep. I picked the few that are more common and simply stated them.

    In this situation the PCP would be best served to do the total work up because care coordination may require the cooperation of different specialties. Few chiropractors, and most naturopaths, spend more time on internal disorders but most chiro’s work in the musculoskeletal world. I think it is expected that they would either do a comprehensive work up or make the approriate referral as soon as possible. If not, then they would be performing below their standard of care.

    Issue here is that most of the discriminatory comments and posts here do even know what the standard of care is for chiro’s and naturopaths. I’ll give you a hint, it’s the same as an MD. Instead, however, we see an organized slander campaign intended to errode the public trust in competing health disciplines. Should we not compare disasters in all professions to get an objective view? Or should we over blow the very few mistakes on one side and call it a problem exclusive tp that world?

    My point is, however, that as primary contact providers we are tasked to assess and either manage or refer. I’m not going manage this particular case so my first concern is to r/o a potential disaster which, in this case, is a DVT. For the record, half of my patients are referred to me by MD’s and they know first hand we do a great job. The truth her eis that the overwhelming vast majority of chiro’s and naturopaths would have handled Dr. Lipsons clinical situation wel within the standard of care for all primary contact health providers.

    Also, your assumption that any risk in a non MD setting with worthless because there is no value in what we do is a baseless assumption. it is faulty thinking. at least it’s discriminatory to say the least. There is tremendous value in what we do. There is significant evidence that what we do is safe, effective, and less costly than our competitors, who see bashig us here daily. You think we just make stuff up and trick the patients? Please.

  17. #17 Adam_Y
    December 9, 2009

    Ahhh yes DrWonderful a man when pressed to actually provide criticisms on the papers involving chiropractics and stroke ran away.

  18. #18 A PCP
    December 9, 2009

    Dr. Wonderful- what makes you suspect a DVT? Based on what is presented here, it is not even on my differential.

    If you want to rule out a potential disaster, try ruling out decompensated CHF, an MI or a PE. Consider the fact that the ACE inhibitor that he is likely on might be causing his cough, and switch it to an ARB. Get an ECG, chest x-ray, and an echocardiogram.

  19. #19 DrWonderful
    December 9, 2009

    daedalus2u- Thank you for your explanation. I am not an internist. But then again niether is an orthopedic surgeon who would have handled the situation exactly as I did if he saw the patinet first. So what you are saying is…after the doppler came back negative (zebra, yes) the referral to the PCP would have been appropriate and the chiropractor would have been practicing within the standard of care? Bilateral leg pain does not automatically rule out DVT (it doe shappen rarely) although it needs to be rule out quickly.

    Seriously though, what would an orthopedist have done…order a doppler and then refer if negative. Why should I be held to a higher standard? You seem to be confusing the issue of practicing primary care and being a primary contact provider. There is a huge difference. The point is if that was your brother that I saw he would have gotten very good and appropriate care at the primary contact level. This is exactly how a primary contact provider should handle the situation.

    Also, I understand and continue to state that much more information would be needed in this case and that many more questions would have been appropriate. I even tstated that in my answer. However, if you read comments number 1 and number 2 in this thread you will see why I did not bother to ask for more information as the moderator said none was available. Ok, it’s a baited Skeptics test and not the real world but I think I did very well and the patient is exactly where they are supposed to be.

  20. #20 daedalus2u
    December 9, 2009

    DrWonderful, I am not an internist, I have never spent a day in medical school. My training is in chemical engineering, which encompasses all other types of engineering including biomedical engineering. I do know the limits of my expertise. I don’t know if my analysis is correct or not. I hope that people with more knowledge than I have will tell me if I guessed right. I gather that person is not you.

    The exam such as it was referred to bilateral edema, not bilateral pain. To me, those are significantly different and imply different pathologies. That they are not different to you is curious.

    You say you would handle it as well (or as badly) as would an orthopedic surgeon. Are orthopedic surgeons trying to present themselves as PCPs? Are you saying you are not capable of acting as a PCP? If you consider yourself to be an exemplary example of a chiropractor, are other less exemplary chiropractors capable of being PCPs?

    Why are chiropractic organizations trying to obtain PCP status if the run-of-the-mill chiropractors are not capable of acting as a PCP? Why pretend to be a PCP if all you are going to do is refer out to a “real” PCP? All that does is add cost to the patient and delay when the patient can get effective treatment. I appreciate that the “cost” is money in your pocket, but the delay in diagnosis and treatment comes out of the patient’s health.

    The only things you can treat effectively are non-time critical musculoskeletal issues. Those can be treated after a referral from a real PCP just as well. Time critical issues, stroke, infections, etc, can’t be treated as effectively when treatment is delayed by going through an ineffective PCP and getting a referral for a second appointment.

  21. #21 DrWonderful
    December 9, 2009

    A PCP- I just took a stab at it because we could not ask questions. I honestly had questions but saw they were not permitted. I chose to be obnoxious because one thing I have learned here is that if I identify myself as a chiro I will never win any discussion. The discrimination is immediate, unrelenting, and fierce. Which is why we need legislation.

    Anyway, this case is not a scenario a chiropractor would typically face as it is more for internal medicine. Some chiro’s do more of it and I trust they would do well. Actually any medical specialty would refer to the PCP or internist, wouldn’t they? Seriously, wouldn;lt an ortho do the same thing? I do know both a chiro and ortho would likely order a doppler to r/o DVT and move the patient to the right care setting. The swelling the legs made me wonder as sometimes in a musculoskeletal setting a DVT will present as calf/leg pain with some swelling. so we are on alert for them as we tend to see them first.

    I wonder how the PCP’s would do with a neurologic presentation or would they assess and refer to a neurologist?

    Let’s be real here. Do you know how many PCP’s have
    misdiagnosed full blown rotator cuff tears or labral tears as “bursitis” or order an MRI on every LB single case and if there’s a bulging disc just assume it’s the problem and treat with rest and a DosPak?

    Let’s be real. PCP’s are as bad at fully working up musculoskeletal disorders as I would be at fully working up an internal medical problem. Although I might do better comparatively. That is not the point. The point is the patient would have been handled safely and within the standard of care and put in the appropriate care setting.

    Let’s keep it fair.

  22. #22 Dianne
    December 9, 2009

    I would first r/o DVT w/ doppler ultrasound and if negative consider Emphysema, CHF, Lung CA, etc and refer to PCP. How’d I do?

    Why is DVT at the top of your differential? Dopplers are reasonably easy, quick, and safe tests to obtain but I’d be hesitant to use them as my only initial approach.

    Personally, I’m thinking lung cancer, but that’s partly because I’ve got this hammer and all those spiky things look like nails to me. And jumping to your favorite disease is NOT the way to approach a case like this….

    So, the differential: A cough can be caused by a number of conditions, some of which are less than obvious. By system:
    1. Lungs: He could have a chronic cough due to COPD, lung cancer, cancer with mets to the lungs, infection (fungal, TB, or even just bronchitis). Bronchialectasis seems unlikely based on the dry cough, but not completely impossible. Restrictive lung disease, pulmonary fibrosis, and PE should be considered as well. I’d be interested in a chest x-ray as a first test. Also further history: any history of hemoptysis, employment and other exposure history, family history, any history of recent travel to start with. (PalMD never said we couldn’t ask questions, just that he’d given the history he wanted to give.)
    2. Cardiac: He may be experiencing a CHF exacerbation. The lower extremity edema supports this more than a DVT/PE. Alternately, he could be experiencing valve problems, cardiomyopathy from other causes (infectious, amyloidosis, valve). I’d like to get an EKG and echo to evaluate this aspect.
    3. GI: GERD can cause a chronic cough, even in the absence of overt GI distress. A trial of proton pump inhibitors might be warranted.
    4. Head and neck: A head and neck tumor might cause a cough through local invasion or metastatic growth. Seems less likely with no change in voice, but by no means impossible. If no obvious cause found referral to ENT might be reasonable, especially with the smoking history. Does he have an EtOH history as well?
    5. VTE: Could be. A doppler wouldn’t hurt anything, although what does a negative doppler prove? The thrombus might already be in this lungs and his legs now clear.
    6. Other: Psychogenic, neurologic, paraneoplastic (my first flippant thought was “just throw him in a PET scanner and see what lights up), exposure….there are lots of possibilities, depending on just how evil Pal is being.

  23. #23 daedalus2u
    December 9, 2009

    “Let’s keep it fair.” Huh?

    Fair to who? Chiropractors wanting to play at being PCPs? Or patients wanting to get prompt, effective and cost-effective medical treatment?

  24. #24 PalMD
    December 9, 2009

    Well, in my not so humble opinion, I thought A PCP did a nice, succinct job, and Dianne as usual and as expected did a nice, thorough job.

    I bring this up to show the kind of thinking that goes with this problem. This could represent something completely benign or something immediately life-threatening, and a PCP must have the knowledge to approach this correctly.

    Anyone with a chronic cough (> or = 8wks) deserves a chest xray. This guy already has heart disease, so something heart-related is pretty high up on the differential, and he has greater than 20 pk-yrs of smoking so he is at pretty high risk of lung cancer and also COPD.

    I’ve seen patients who presented like this who had primary head and neck tumors, GERD, or post nasal drip. More data will of course help with the differential.

    Further re-examination showed a normal pulse ox, no elevation of jugular venous pressure, and no supine dyspnea. A resting EKG showed evidence of prior MI.

    A chest xray showed some flattening of the diaphragms but was otherwise negative.

  25. #25 Karl Withakay
    December 9, 2009

    @DrWonderful,

    Dainne: “Do we get to ask any further questions? You’ve left out a couple of points that would, IMHO, be helpful. (Not that I’m really qualified to answer the post since I’m a specialist.)”

    DrWonderful: “With such a limited history and exam, which is considered substandard by the way,”

    DrWonderful Later: “However, what is striking is the tone you took with me as compared to Dianne. Why not scold her like you scolded the chiropracic physician?”

    Can your astute powers of observation not discern any difference in the way she politely asked and the way you snarked? Perhaps you reaped what you sowed.

    Additionally, PalMD is actually giving a big benefit of doubt by skipping past the question of whether the workup and exam done by an ND, DC, or other AltMed provider would be anywhere near as throughout and complete as the one presented in his example.

  26. #26 DrWonderful
    December 9, 2009

    daedalus2- Seriously, you demonstrate a pathology I now see is so common among this group of skeptics. This new skeptic movement is so abberant. Do you think it will last? To you everything is just an argument that you need to overpower and forcibly control. Almost like you have to smother and suffocate people who may think differently than you. As if I am a challenge or a threat to you? I really do notthink I am. Were you abused as a child? While the rest of the functional world tries to work together to solve problems using values such as patience, tolerance, etc. Part of having an opinion should include being well informed and listening to what people say. Not crushing and attacking them and manipulating everything they say. Are you at war with everything every day? Do you feel justfied to be self righteous only because you have crafted a skill at being argumentative?

    Because that’s really all this group is good at. Arguing. Put before a reasonable and impartial, well let’s say “audience” for the lack of a better term, you look like crazy mean folks who have a lot of pain inside…and a competing agenda.

    Anyway, to be clear chiropractic physicians are not asking for any expansion of scope beyond their training and already perform very well as primary contact providers. The legislation merely puts us in the new plan exactly as we already are in the current system. Those who are ringing the alarm bells fail to mention this and many other facts, but they have an agenda obviously.

    Earth to skeptics, please return to home base and join the human race again without being so defensive, angry, arrogant, manipulative, and easily threatened. We need critical thinking but the rest of this bullshit cannot be tolerated…and won’t be.

    I do apologize for making a mockery of this discussion sometimes but when I read some of this stuff I almost burst out in laughter and cannot believe my eyes. How slanted and biased it is. How easily manipulated you are by your leaders. I tend to find my dark side and have fun with y’all. I do apologize but I cannot take any of you seriously at all when you take yourselves so insanely seriously.

    Listen, I’m not a PCP and have no desire to be. They do great work and we need more of them, clearly. They do their work very well. But, I do my work very well too but you won’t see it. And y’all need to stop attacking others without even trying to fix yourselves. Medicine is very broken, so why the organized attack on CAM?

    Anyway, the work force gaps are going to be closed with a greater emphasis on primary care by primary care docs but ALSO by bringing in a bunch of “primary contact providers” into the mix TO WORK WITH THEM. How? Through new coding and reimbursement, education and research grants, etc and all sorts of new health policy incentives to free up the system to allow people to do what they are trained to do. But mostly by ending provider class discrimination by health insurers.

    I am trained as primary contact provider. There is no threat to public safety but there is a threat to the MD ego (and only the ego) and also to the insurance system. We could do with a lot less of both those things.

  27. #27 David
    December 9, 2009

    are approved by their own regulating body to practice “primary care” after four years of naturopathic school.

    4 years of learning nonsense is worse than no training at all.

    Also, you could compare MD/DO students to naturopath students. Accepted applicants to medical school have good grades in at least a moderate number of science courses, and typically graduated in the top of their college classes. The students at naturopathic school are generally both less smart and less well educated.

  28. #28 BD Palmer
    December 9, 2009

    PalMD:

    The process of developing a differential diagnosis means engaging your brain, and then asking for more info to help winnow down the options.

    Dr. Wonderful:

    Having read Dianne’s comment at #1, and then seeing your response that questions were now allowed, well, I decided not to ask for more information[tl;dr entheta snipped]

    *facepalm*

  29. #29 PalMD
    December 9, 2009

    Whatever a “primary contact provider” is, I don’t want my patients seeing one. How many levels of quacks do my patients need to pass though before they get to me?

  30. #30 Nat
    December 9, 2009

    Hi PAL

    There’s no way I’m an altmed. But I also lack an MD although I’ve spent way too much time hanging out in medical schools as a PhD public health nerd. But I’ll take a stab at a differential that I’m familiar with.

    PAL sez: “patients who presented like this who had primary head and neck tumors, GERD, or post nasal drip.”
    “Further re-examination showed a normal pulse ox, no elevation of jugular venous pressure, and no supine dyspnea. A resting EKG showed evidence of prior MI.

    Pulse Ox and jugular venous pressure are normal when awake and breathing is normal while supine and awake. But this may not be true when the patient is asleep. MI, diabetes, nocturnal cough, he’s a 60 year old man, head and neck tumours and GERD are all markers of sleep apnea. Post nasal drip may be a side effect of a previous surgical intervention to correct this (which is often ineffective).

    Another possibility is that the COPD caused by the smoking might is not evident during wake but may manefest during sleep. How this relates to chronic cough I do not want to guess.

    Hammers and spiky things that look like nails from me too though…

  31. #31 Karl Withakay
    December 9, 2009

    RE:#26
    DrWonderful channels Depak Chorpa rather well, don’t you think?

  32. #32 Karl Withakay
    December 9, 2009

    Nuts @#31, Typo: Deepak, with two e’s

  33. #33 daedalus2u
    December 9, 2009

    Yes DrW, I was abused as a child. That has made me especially sensitive to abuse and exploitation of others by perpetrators.

  34. #34 Dave
    December 9, 2009

    Hmm, thread has gone to whackey land. My DDX:
    1. CHF
    chronic systolic dysfunction vs. diastolic dysfunction
    2. COPD
    3. OSA
    4. Pulm Htn 2/2 to copd or osa
    5. ILD
    I would not go leaping for VTE at this time because he has symmetrical LE edema. Acute DVT / VRE would most likely cause asymmetric LE edema. Chronic VTE causing Pulm Htn could maybe cause symmetrical LE edema.

    Other questions: any orthopnea, or PND on ROS? No weight loss but how about weight gain?
    On exam: any JVD or hepatojuglur reflex?
    Has he ever had a TTE?
    What were the finding on his cath?

    Since we are talking outpt, would start with CXR, BNP and basic panel.

  35. #35 PalMD
    December 9, 2009

    Please see comment #24

  36. #36 BD Palmer
    December 9, 2009

    So our lad has some emphysema but no major goomba in his lungs and no CHF. That leaves

    - ACE inhibitor
    - Allergies/irritants
    - GERD
    - Ceruminosis
    - Dysphagia for some weird reason
    - Something weirder

    on my list. But I should mention that primary care isn’t my gig.

  37. #37 babdoc
    December 10, 2009

    Spirometry anyone? That might point to a pulm problem. I’ll leave it at that since previous posts (esp Dianne) had good DDx.

    Actually, ACEIs were the first thing that popped into my mind. Good practice since I have a cardio/pulm exam tomorrow. :-)

  38. #38 Hildy
    December 10, 2009

    I don’t differentialise; I’m now a surgical resident after having been an ED resident, and I’m planning on completing training as an orthopod.

    (so, for DrW, orthopods are still doctors, and they can still do a modicum of basic workup. this is especially so for residents who need to be able to do day to day workups on the ward.)

    My approach is the standard shotgun ED approach: I’d get bloods (including an ABG), a CXR, bedside spirometry, and probably do a basic bedside echo (at least enough to get an EF, which takes about 3 minutes). These basic tests are almost free and would give a lot of useful information.

    Obviously this man already has a cardiologist who is looking after his heart post cath. If the spirometry diagnoses CAL, I’d send him to a respiratory physician as well. Both forms of CAL can have coughing, and a normal pulse ox doesn’t rule out ABG changes. Similarly, if there’s a restrictive defect on the spirometry, I’d get a highres chest CT looking for early fibrosis as a cause of cough.

    Otherwise, I agree with the other people above about common causes of cough: asthma, allergic rhinitis / post nasal drip, ACEI, GORD.

  39. #39 PalMD
    December 10, 2009

    So, in a PCP office, you generally work with simple tools. The patient seemed fine—no signs of CHF, a normal CXR (which is read out later by a radiologist).

    As many pointed out, he has coronary disease so is likely on an ACE inhibitor, a medication that will help prevent progression of heart disease. A certain percentage (I can’t remember but I want to say 7 or so) will develop a cough that won’t go away until you stop it. I stopped his ace and switched him to an ARB and the cough went away.

  40. #40 JohnV
    December 10, 2009

    @DrWonderful

    “Almost like you have to smother and suffocate people who may think differently than you. As if I am a challenge or a threat to you? I really do notthink I am. Were you abused as a child? While the rest of the functional world tries to work together to solve problems using values such as patience, tolerance”

    {snip}

    “Earth to skeptics, please return to home base and join the human race again without being so defensive, angry, arrogant, manipulative, and easily threatened.”

    So I need to ask, does it feel weird typing all of those same things during the same diatribe?

  41. #41 Dianne
    December 10, 2009

    This post is an example of why you shouldn’t have specialists trying to do primary care: I forgot about two very common, relatively benign causes of chronic cough: ACE inhibitor use (and a diabetic with heart disease is VERY likely to be on an ACE-I) and post-nasal drip. Being an oncologist I focused straight on the history of smoking and went looking for the tumor that I tend to expect in any smoker…in short, I went looking for a nail to go with my hammer. A primary care physician would have a more open mind and differential diagnosis.

  42. #42 Bill Maher
    December 10, 2009

    So there you have it. The man was being poisoned by the pharmaceutical industry.

  43. #43 Dianne
    December 10, 2009

    I don’t differentialise; I’m now a surgical resident

    Cue the surgeon jokes…

  44. #44 VikingMoose
    December 10, 2009

    How can you tell specialty from how the doc catches the elevator?

    Internist: catches the door with the hand. No worries about injuring it.

    Surgeon: catches door with foot.

    Orthopod: Catches door with his head.

    (credit: a colorectal surgeon)

  45. #45 DrWonderful
    December 10, 2009

    Yes John, I feel very weird in here. This type of atmospsher is no unatural for me. Sort of nagtive and bruising, but whatever. It’s not like anyone in here would evergive a shit about me anyway!

    I do admit I did not read Pal’s question carefully and did not think to ask questions. I assumed he was going ot prive no more info as was his repsonse to Dianne. Reading the thread however I am actually happy to say we are better educated in this than you would think. Iknew where to put the patient int he system and despite what you think I did not try to adjust C2 to fix the problem. We do not do that despite what you say.

    I remember listening to a program about primary care given by someone at CMS years ago. She was an MD. She felt that chiropractors, based on their education and where they currently sit in the field, actually fit 4 of the 7 accepted definitions of primary care (some of which are very, very, very broad) . You are focusing this discussion soley on a nrrow strip of what you do every day, and what your opinion is, without even knowing there is so much more info than you know. I beleive she was using the 7 WHO definitons ( but cannot remember exactly what her references were. She was actually advocating for a greater role for us as primary contact providers bcause we fit a larger niche than most people know.

    Obviously we are not prescribing or giving vaccines but we do have a front line differential diagnosis capability that is now being considered as a way to close the work force gap. Same as nurse practitioners, PA’s, ND’s etc. The point is we are at the point of entry and can asses and make the appropriate referral, not always to the PCP but to a specialist. Pretty much what we do already. You see life on the ground will not change much for you or your patients but policy is calling for a greater system wide emphasis on primary care, prevention and wellness. I understand that to mean greater coding capabilities for y’all and more systemwide accpetance for what the rest of us are capable of, and already are, doing.

    Again, you’ll need to understand what they mean by “primary care” for you and understand in our instance they are using us as “primary contact” and want us to expand roles in prevention and wellness (do not need an MD for that) I do not think anyone expects or advocates for chiro’s and ND’s to manage complex issues they are not trained to do.

    So the situation your leaders and drummers are freaking out about may not be what your big brains think it is. Sort of pattern for you folks huh? Sort of already know it all and will argue fiercely until someone proves you wrong. But most people don’t give a shit and just walk away leaving you to think you were victorious and only enlaring the brain pathology even more? It’s called arrogance and it is pervasive in here.

    Relax, the world is not going woo but also, at the same time you do not already know it all.

  46. #46 madder
    December 10, 2009

    To borrow Dianne’s metaphor, DrWonderful is also looking for a nail to go with his hammer. Convinced that everyone commenting here is a big meanie, and that PalMD’s training is inferior to his mad chiro skillz, “Dr”W missed the whole point of the exercise. This was a necessary step for the rants that followed, which were the goal all along.

    To begin with, questions were not disallowed. Real doctors work from incomplete histories all the time because that’s what they get, not because they like them. Working up a DDx from an incomplete history is an exercise in identifying possible conditions, paying special attention to those that may be immediately life-threatening, and deciding what new information would be most helpful for identifying the cause of the symptoms. So statements that “I would run text X and inquire about presence of Y in patient history” are not only allowed, they’re part of the exercise.

    But that doesn’t fit with “Dr”Wonderful’s idée fixe of the Great Medical Tragedy: that all real physicians are actually incompetent buffoons who conspire to persecute the real healers who crack backs. Why, if everybody only got their back cracked once or twice a week, and purchased the amazing supplements that just happen to be sold in the front office, all disease would be immediately vanquished!

    Sorry for feeding the troll, everyone, but its lies should be pointed out lest passersby think it has a point.

  47. #47 BD Palmer
    December 10, 2009

    It’s not like anyone in here would ever give a shit about me anyway!

    It’s not you. It’s the learnin’ inflicted upon you by that anti-medicine cult of yours.

    Subluxations that might cause asthma don’t exist.

  48. #48 TTabetic
    December 10, 2009

    Any sane person with a 9th grade education or above who reads about chiropractic would consider it complete, utter bullshit.

    “Ohh look, i can crack ur back and fix the subluxie-dos and make all that life energy flow better to fix ur allergies.”

    What a crock.

  49. #49 Nat
    December 10, 2009

    PAL sez “I stopped his ace and switched him to an ARB and the cough went away.”

    Ok. That makes sense. Good reminder not to engage in DDx in the real world without appropriate training too.

    Might I ask what your thinking as a PCP was about the OSA issue that a few of us suggested as a possibile medical history item?

    PS Could we all stop feeding that troll please…sheesh…

  50. #50 WcT
    December 10, 2009

    I’m sad that I missed all the fun! I was interviewing for residency spots.

    I think everyone did a great job of putting out that differential. I’m a little disappointed that DrWonderful still seems to think that he did an OK job with his “differential,” or that he/any of his chiropractic brethern could be PCPs.

    I think this is because DrWonderful understands what the end product of running a differential looks like – “oh it could be X, Y or Z, and I’m going to do 1, 2, and 3.” What he has failed to understand is the thought process that LEADS to a differential diagnosis – he just kind of jumped to “duh it’s a DVT.” In the process his plan would have lead to a waste of healthcare dollars and he STILL wouldn’t have helped the patient. He also would have failed to refer the patient to a realll PCP.

    Maybe PAL, you could kind of post on that thought process? How does a good doctor get from that scenario to the list of things on the differential. It’s alot more complicated than pullign diagnoses out of ones butt.

  51. #51 A PCP
    December 11, 2009

    @WcT: I’m not PAL, but I am an internist. Making a good differential takes practice and experience more than anything else. When you see a patient and get their chief complaint, it’s like making a huge list in your head. The differential (for cough, in this case), is huge. As you get more history, you start crossing things off your differential. As you ask questions, you cross more things off. Your physical exam allows you to narrow things even more, until your are left with just a few possibilities.

    I thought this was a good case, because it illustrates the above. It also shows (in my not-so-humble opinion), why a good PCP is needed. As the specialists above commented, their differentials did not remain sufficiently broad, and they missed the diagnosis.

  52. #52 A PCP
    December 11, 2009

    Here’s a case that I saw this week that I think illustrates my above point of why PCPs are so important.

    A patient came to see me with elevated BP. She was feeling “off” and took her BP, which was 160/110. She called my office and came in. She had no history of hypertension (her husband does, which is why she had a BP cuff in the house). Actually, she had no chronic medical problems at all. The last time I had seen her was 3 months ago, when I did a pre-op evaluation. She was having a cervical discectomy done. Her BP was normal at that visit.

    So- a huge differential, right? Malignant HTN, renovascular disease, pheochromocytoma, etc, etc.

    I got more history- she was doing well. I asked her how her back was- fabulous. No pain at all, and she was so happy that she had the surgery. She didn’t even need any pain meds any more!

    That was the red flag for me. I asked here more about the pain meds- she had been on oxycodone for a few months before the surgery and after it (prescribed by ortho). She had a bit of a hard time getting off of it, but now was off of all narcotics for the past two weeks. Her ortho had given her “a withdrawal pill.” to help with the symptoms. She had stopped this pill 2 days ago.

    A quick call to the pharmacy confirmed that the withdrawal pill was clonidine.

    My diagnosis? Rebound hypertension from abrupt discontinuation of clonidine.

    My point? If she had self-referred to a cardiologist for this, my suspicion is that she would have bought herself an echo, a stress test, perhaps a 24-hour ambulatory BP. Her “hypertension” would have corrected itself over a few more days, and all of that time and money would have been wasted.

  53. #53 daedalus2u
    December 11, 2009

    APCP, excellent example of treating the whole patient.

    The process of a differential diagnosis reminds me of Feynman’s Cargo Cult Science, going through the motions of science without having the intellectual integrity to admit to mistakes in logic, data, or preconceived ideas.

    That is why DrW can’t do a differential diagnosis, he is caught up in his cult-like beliefs in subluxations which can’t be questioned or his whole world-view comes tumbling down and he has a narcissistic injury. It isn’t a lack of specific knowledge, it is a lack of the ability to reject ideas that are wrong.

    The difference between medicalized cults like chiropractic and real medicine is the ability for self-examination and correction. There is a famous quote about what fraction of what is learned in medical school turns out to be wrong 25 years later. How much of what is learned in chiropractic school or naturalopathy school is found out to be wrong 25 years later? Nothing because no one in those fields has the intellectual honesty with themselves to admit that they were wrong. That is why chiropractic, homeopathy, acupuncture, CTM, etc are all unchanged from ancient times (and yes, 100 years ago is ancient times in medicine). Those who practice them don’t have the intellectual honesty to test what they are doing and then abandon it when it is shown it doesn’t work.

  54. #54 gaiainc
    December 11, 2009

    You mean we’re supposed to talk to the patient? Get a history? Really? Are you sure? That seems soooo radical. /sarcasm/

    Somewhere in my training I was told that the patient’s history will tell you what is going on 75-80% of the time. Physical exam and any other studies are done to help differentiate between possibilities, but not always necessary. I try to teach my residents that the patient is trying to tell you a story and that story has to make sense somehow. If something doesn’t make sense, then you have to consider you have the wrong story/plot and it’s time to reassess. The other thing I try to teach them is that sometimes you need time to figure out what is going on, that things change and you have to be willing to change along with them. Common things happen commonly.

    FYI-according to Micromedex, incidence of ACE-I induced cough ranges from 7-15%.

  55. #55 KB
    December 14, 2009

    I’m trying to do this without looking at the other comments, so sorry if this is a repeat of something already said or corrected:

    I would get a chest x-ray, an EKG, and maybe sonogram of kidneys?

    Differential diagnosis:
    the cough could be a side-effect of BP medication
    congestive heart failure from CAD or renal artery stenosis, leading to pulmonary edema
    emphysema
    lung cancer

  56. #56 Dianne
    December 14, 2009

    Hey, this was fun! Can we have another one?

  57. #57 PalMD
    December 14, 2009

    Maybe, but i ain’t showing any smears or talking JAK2.

    Or maybe i will and someone can skool me.

  58. #58 WcT
    December 14, 2009

    If we’re voting, I think the next case could have a chief complaint of syncope. It’s another one with a brooooaaad differential, and another one that would be easy for someone without good PCP training to both overreact to a mild problem and/or “blow off” a serious problem.

  59. #59 Dianne
    December 15, 2009

    Maybe, but i ain’t showing any smears or talking JAK2.

    AWWW!!!

    But Jak2 is the easy part. It’s when the Jak2 is negative but the hemoglobin is still 20 than things get complicated.

  60. #60 Dangerous Bacon
    December 15, 2009

    From the initial information provided, my leading possibilities were:
    1)CHF
    2) COPD-related
    3) Lung malignancy
    4) Drug reaction (i.e. ACE inhibitor side effect)

    DVT/PE was not an initial consideration (sorry, does not compute from signs and symptoms, Dr. Wonderful).

    And I’m a pathologist. What does this say about the wisdom of having a chiropractor as your health gatekeeper?

    Doc Wonderful: “To you everything is just an argument that you need to overpower and forcibly control. Almost like you have to smother and suffocate people who may think differently than you.”

    Bad medicine is not an alternative thought process.

    Maybe alt med needs to produce a movie featuring a different universe in which anecdotes and fables are curative. They could call it “Inglorious Alties”.

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