Too often, practicing physicians and residents skip steps

Internal medicine requires knowledge, deduction, and many skills: history taking, physical examination, analyzing diagnosis tests. When confronting a new patient problem, we use our brains to work on finding a diagnosis. Much like police detectives, we would like to have brilliant diagnostic epiphanies, but often we make our diagnoses by painstakingly collecting all the clues and doing the necessary boots on the ground work.

We had a woman admitted to our service with confusion, decreased appetite and weight loss. In the ED, they diagnosed chronic kidney disease stage V: creatinine > 5 and BUN > 90. She had a 10-year history of type 2 diabetes. She had a history of ingesting high doses of salicylates and had a mildly elevated level.

The next morning as we are making rounds in the ICU she was on the bed pan. We asked the nurse to check a residual urine, because that is what we must always do with an unknown elevated creatinine. In fact her residual urine was 245cc, despite no hydronephrosis on renal ultrasound.

The next day her appetite had returned and she no longer was confused. Three days later her creatinine was 1. Urological evaluation is the main plan now.

We had no good reason to suspect urinary obstruction, but we often are surprised with apparently newly elevated creatinine levels. We see such patients all too often. Finding obstruction when we did saved many resources.

While we love our diagnostic eureka moments, more often we get to the diagnosis through a deliberate process of touching bases and seeing what clues arise on our journey. Too often I see practicing physicians and residents skip steps. Too often I skip steps. When we skip steps we can miss the diagnosis in our omissions.

We owe our patients the deliberate process that leads to success. We need to touch the bases.

Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.

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  • Steven Reznick

    Wasn’t her bladder distended on initial physical exam? When they used the ultrasound on her kidneys did they not take a peek at her bladder? You supported this woman through her initial crisis while you went through the differential diagnosis without doing any harm. Yes it would have been great to have gotten it correct on the first try. I suspect the next 1000 patients who present that way will get a look at their bladder.
    The best advice I got from an experienced clinician when I was training was start at the top and work your way down to the feet and look at everything in between. You still may miss stuff in a frenetic Emergency Department setting but at least you looked

    • Robert Centor

      I saw the patient several hours after admission. No one had checked the bladder, and the kidneys did not show hydronephrosis. The patient left the hospital with a normal creatinine!

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