What does a good clinician use to determine a diagnosis and a treatment plan? Of course, there are the senses. I always heeded remarks from my professors about what I saw. If one could tear themselves away from the EMR and look at their patient, they would discover an entirely new world. Looking at the face and hair, we can discern whether the patient has pride in their appearance, has combed their hair today, has trimmed their mustache and beard, or shaved their face; did they take the time to wipe away the ketchup from their bacon and eggs and French fries? Are their clothes clean and pressed, or do they look like they were doing a low crawl through a muddy pig pit and presented immediately after attending this event? Keeping that theme, have they showered before they came to the office, or do you smell pig muss from the waiting room? There is no better way to clear your afternoon consultations than to have that person enter and sit in the crowded waiting room, only to have the other patients exit the office because of the odor. A compassionate provider will elicit a personal history and discover this unfortunate person lacks companionship to eat with other humans because there is something wrong with society, not just his appearance. Time spent with patients requires some hygienic components based on their age, physical disabilities, or home situation. The physical presence of our patients is a powerful indicator of other physical or psychological problems they may have encountered in our office. Are we taking the time and the first step to recognize them?
Failure to diagnose is number one on the hit parade of reasons for making a professional error and welcoming a blue summons informing you of litigation. If you practice long enough, you will more than likely receive one of these papers. Litigation causes a clinician to take a fresh look at their notes to see if there may have been a medical error or to see what they missed that may have been causative in a faulty diagnosis. This is the reason behind forming a differential diagnosis.
So many patients, their families, and their attorneys have no idea of the devastation that this lawsuit may bring to the clinician. They doubt themselves and their ability, look for gaps in their learning, and have deep concerns for their patients and their outcomes. They fear legal action because they are not adequately insured, and the facility that hired them will love to make the clinician the only scapegoat.
Why did I entitle this article in the manner that I did? Our new age seemingly does not feel that vaccinations are good enough and are fraught with countless potential problems. If a sizable number of the issues were occurring in our medical system, you can be sure vaccinations would stop. The truth is that reactions are exceedingly rare. Literature is available to families who have questions or concerns. Today’s provider differs from when I spent my forty-seven years as a PA. Diseases that have been eradicated, such as I wrote in my last article, are rearing their ugly faces and are returning once again to create fear and turmoil in patients and providers alike.
As an example, I wish to bring up pertussis: whooping cough. It is not a virus but a highly contagious bacterial respiratory infection characterized by numerous everyday symptoms. The presentations are about sneezing, coughing, and a low-grade fever. A differential diagnosis must always be considered, and a mechanism for the parent to contact you as soon as possible if things change. Little Johnny may present with rhinorrhea, a stuffy nose, low-grade fever, and a slight cough. How many little Johnnys have you seen in your practice during the past month? The patient returns because of parental concern; you never want to dismiss a parent’s fears. You decide to culture his nose and throat, and because of the news on TV, you order a nasal culture for R/O Pertussis. It returns positive. You can reassure Mom that this can be treated with bed rest, fluids, and antibiotics. I want to inform them of the disease course and isolation parameters for visitors to the home. They may require supportive care, including small meals. A cool mist humidifier is suggested as it loosens mucus and sooths the cough. It is time to get the family into good hygiene mode, which means underscoring the need for handwashing and covering their noses and mouths when sneezing and coughing. It is imperative to disinfect surfaces that an unprotected sneeze or cough has contaminated.
What are the potential complications of this disease? They may include worsening cough, pneumonia, middle ear infections, loss of appetite, fainting, sleep disturbances, dehydration, seizures, encephalopathy, brief periods of apnea, and even death. Other symptoms can include sudden uncontrolled coughing fits, a whoop or high-pitched sound during inhalation. A person with severe coughing and mucus tends to develop vomiting. A weak child can more easily experience aspiration, severe lung damage, and even death. These kids tend to be exhausted, and Mom wishes to see them screaming and jumping on the furniture. The secret to making Mom happy is to prepare her and offer authentic access to nursing advice by phone.
Little Johnny can have a poor outcome because of the lack of a DD. It is essential for the new clinician NOT to use a template and utilize the training they have acquired in physical diagnosis. Empty your head of a preconceived diagnosis and run down a list of treatment plans and medications. Take the time to look carefully and to make a good and acceptable diagnosis. This can become a lawsuit and now is the time to check your malpractice insurance. A better time would have been before entering this employment but going beyond hospital or practice insurance and purchasing your own personal liability insurance. I tried CM&F and have never regretted it during my career. I hope that you make the same decision.
Written For CM&F By: Robert M. Blumm, PA, DFAAPA, PA-C Emeritus
CM&F Clinical Advisor
