The Diagnosis Russell La Forte, M.D. Area Medical Director Internal Medicine
The Diagnosis • Two Meanings • Diagnosis = Patient’s Disease • Diagnosis = The artful process by which the patient’s problem is uncovered
The Diagnosis • Neither of these is what “coders” mean by “diagnosis”. • Billing forms usually refer to “working hypotheses” or “working diagnoses”
The “real” Diagnosis The right answer to the problem NO uncertainty Can be difficult to tie to the patient’s problem Is often never made or even sought The “working” diagnosis Conveys the current level of uncertainty Suggests what work-up will lead to “the diagnosis” What’s the difference
Examples • Hypertension – not a “real” diagnosis • Why? Doctors do not understand it sufficiently • If you have HTN, you should have a physical examination and lab tests to look for • 1. A real diagnosis (about 5 percent of patients) • 2. Other “real” diagnoses that are associated with chronically elevated blood pressure. Example – Coronary Artery Disease
Hypertension • Cushing’s disease • Mineralcorticoid secreting tumor • Secondary hypertension from renal disease • Renovascular hypertension • Coarctation of the Aorta • Pheochromacytoma
Very vague – complaint based Less vague – complaint based Syndrome - usual system specific Lab based – often organ specific Abdominal Pain, Rash Dyspepsia, Dermatitis PUD, lupus Elevated liver enzymes Working Dx - Uncertainty
Often patients without firm diagnoses present with some change in their symptoms May or may not be the same disease Irritable Bowel Syndrome – now complains of blood in stool Symptom not part of the Syndrome of IBS Further study indicated New symptoms
Irritable Bowel Syndrome Patient • Number one diagnosis now hematochezia, i.e. blood in stools (a working diagnosis) • Number two diagnosis now Irritable Bowel…although patient may have told the triage nurse that IBS was the presenting problem
Symptoms Body or Mind?
Psychiatric Overlay All symptoms are in the patient’s mind – the disease may or may not be • Most diseases, and all chronic diseases, have psychological components – the sufferer has a mental reaction to the disease • Sometimes this reaction is another disease in itself
Primary Diagnosis • Ideally, this diagnosis is the number one working diagnosis • Different doctors will view which of several diagnosis is “primary” differently • But, when the problems are related there is usually a common pathophysiologic entity that can be listed
Example • 54 yo male presents to the Emergency Department after passing out at a local restaurant. Work-up in the Emergency room finds both a bleeding duodenal ulcer and a heart attack. Which diagnosis is primary?
Possible answers • For Inpatient, pick the one with the higher DRG • Ulcer is the primary diagnosis. • Myocardial Infarction is the diagnosis.
Duodenal Ulcer • That’s what caused the heart attack, and timing is everything. • Underlying or ultimate cause • You may never talk the stomach specialist out of it either.
Myocardial Infarction • If the patient hadn’t had the heart attack, they wouldn’t have passed out. You will never talk the cardiologist out of it either.
The Right Answer • “Passing out” is the best working diagnosis. Therefore, I would choose syncope complicated by the secondary diagnoses of myocardial infarction and bleeding Duodenal Ulcer.
Diagnostic Processes • The history and physical examination • The hypotheses are generated at this point • Often, characteristic findings are present that lead to a “real’ diagnosis being made
Chief Complaint • What ‘the diagnosis” working or real seeks to explain • Sometimes the patient doesn’t have a complaint • But they did and that is the reason they are there. They now have a diagnosis and are there for follow-up. • Diabetes comes to mind
More than one diagnosis • If the patient has a complaint, then the diagnosis that explains that one is primary • Otherwise, put the one most addressed in the plan first. • Or, the most serious one
Mrs. Y • CC: I don’t know, I feel fine • PMHX: HTN for 20 yrs, AODM for 15 yr, hyperlipidemia, OA, CAD with recent abn’l cath, HA, dyspepsia, tobacco abuse, seizures • History, physical, labs are all ok.
Ordering diagnosis • What is the proper order of diagnoses? • Depends on the doctor and the day • Endo – AODM • Cardiology – CAD • Neurologist - seizures
Skinning the Cat • CAD is the number one diagnosis • First, there has been a recently abn’l finding • More importantly, it is a serious problem, in and of itself • The others are not particularly serious (OA) or are “diseases” invented to help us prevent serious problems like CAD (HTN, hyperlipidemia, and, to a lesser extent, AODM)
But… • The patient was complaining of their joint pain, and you still put CAD as the number one diagnosis. • Eclipse • I didn’t do anything about the OA except listen to the complaint. • I personally called the CT surgeon because they need an operation.
Multiple Complaints – type 1 • Mr. P is a 34 yo male that complains of chest pain, nightly erectile dysfunction, depression, headache, ingrown toenails, and anal pruritus. • “Depression” is the number one diagnosis. • Other diagnoses are so colored by psychiatric problems that they are not really explainable otherwise. • Further work-up, such as finding he has a serious cardiac defect may change this.
Multiple complaints - 2 • Ms. Q is a 90 yo spinstress with HTN, AODM, OA, depression and abdominal pain for 20 yrs without abn’l findings on examination. • Her arthritis keeps her up at night • Her blood sugar is chronically elevated – not too bad • Her blood pressure remains abn’l on four drugs • Her stomach hurts daily
It’s Hard to Be Humble • Whatever you pick as number one, somebody can explain to you why you are wrong. • Pick the one that the doctor did the most work on as number one. The doctor simply must choose which is the most important. • In this case it would be AODM.
More than One Working Diagnosis • Importance of explaining as much as one can with one hypothesis • Eventually, as people age, they will pile up diagnoses (both real and working).
Diagnosis Deferred • I bet you can’t bill it as that, but deferral is very common in the art of medicine. • IN other words, the patient presents early in the course of a process, and the diagnosis can’t be made on the bases of H+P. The condition is unlikely serious enough to be worked up further at this point. • Most people, including doctors, don’t necessarily realize they are deferring diagnoses.
Example • 25 year old male presents with nose bleeds for about one week, mostly of oozing. The patient is concerned about exposures to chemicals at work. He has been using nose spray for a runny nose and notes that this controls the bleeding as well. His blood pressure was high at work (he has high blood pressure). Unremarkable physical examination except three shallow ulcers inside the nose – two on the left, one on the right.
Now, we could decide to make an exact diagnoses by doing some tests –nasal smears and biopsies. I felt reasonably confident that he had recently had a cold, and the nose spray he used contributed to the ulcers, although the immediate effect is to decrease bleeding. I did nothing further and told him to call back if he wasn’t better in a week off the nose spray.
Therapeutic Trial • A change in medication or treatment is made to assist in making the correct diagnosis. By stopping Mr. X’s medicine, he was taking a therapeutic trial.