Top tips to avoid complacency when faced with a common clinical presentation that may have an uncommon medical diagnosis.
Lifelong Learning in Clinical Excellence | May 17, 2018 | 2 min read
By Michael Crocetti, MD, MPH, Johns Hopkins Community Physicians
When faced with a set of clinical signs that you’ve dealt with many times and the patient isn’t responding in the manner that you expect, avoid complacency and refocus your diagnostic process. Consider alternative diagnoses that can be ruled in or out depending on findings from a more comprehensive history, physical exam, and/or laboratory/imaging evaluation.
When I’m working with pediatric residents or younger clinicians, we often will discuss a case that involves common presenting signs and symptoms but not everything is adding up to a straightforward diagnosis and treatment plan.
What’s different about your current patient?
One of the first things I ask the clinician to do is to think about all of the times they have seen a patient with these signs and symptoms. Depending on their experience it could be a few to many dozen.
I then ask what is different about the current patient. What doesn’t seem to add up? This helps clinicians to refocus their diagnostic process.
The young man in this recent New York Times Magazine story presents to a dermatologist with a few skin lesions—while very common in children there was something about their appearance that didn’t sit well with the clinician.
Why would a healthy appearing 5yo have these odd-looking acute onset skin lesions?
Dig deeper into the medical history.
Dr. Polcari did what excellent clinicians do, and that is probe further into the child’s medical history. She asks one general question about any recent hospitalizations, which sets in motion the path to a correct diagnosis.
Pneumonia is a relatively common diagnosis in children who present with persistent cough, fever, and an abnormal lung exam. However, what isn’t common is the development of fluid around the lung. During the hospitalization, the clinicians manage his condition with antibiotics and a chest tube, which improves his symptoms.
But does anyone ask why this healthy young man with a common condition such as pneumonia developed a not so common fluid collection around his lung? Could this be a rare infectious agent or an atypical aggressive infection? Why does he still have a fever upon discharge from the hospital?
Refocus your diagnostic process.
Dr. Polcari questions that if these skin lesions were common bacterial infections they should have been treated with the antibiotics he received in the hospital. She avoids the complacency of starting a different antibiotic or applying more creams by sending a biopsy of the skin to the lab for analysis.
When it comes back as fungus she knows right away that her care team needs to refocus their efforts on the child’s history of potential exposures. When the resident physician begins to ask the questions a treasure trove of possibilities come to light and the correct diagnosis is made.
Dr. Polcari and her team recognized that things didn’t add up.
They avoided complacency in medical decision-making, refocused their diagnostic process, and saved a young child’s life.