We discovered a new patient on our internal medicine ward bed with a known history of Idiopathic Thrombocytopenic Purpura (ITP) whose admitting note now claimed that she had been running fever for a few days. This gloriously succinct information was accompanied by a detailed mention of a bone marrow biopsy that had been done recently from another hospital showing erythroid hyperplasia. Her CBC showed bicytopenia (A low total leucocyte count and platelet count). We started a regimen for neutropenic fever and while doing so ran out loud many diagnoses amongst our team of competent young physicians. Could this be Paroxysmal Nocturnal Haemoglobinuria? Could flow cytometery help? Was this myelodysplastic syndrome? She had alopecia, could this be Systemic Lupus Erythematosus? One thing was clear. What we held before us was no regular ITP.
My mind craved answers. Embarking on a very Sherlock Holmes approach to solving mysteries I dismissed all the general impressions and attempted to delve deeply into the details. I sat by this patient’s bedside, and initiated an extensive inquisition. She first had uncontrolled bleeding at the age of four, a family history of bleeding and several tests done during her lifetime (current age being 24) trying half-heartedly to reach a diagnosis. There were additional details that indicated that in her case the hooves might actually mean zebras. The hematology resident performed a perfunctory review at our behest and did what hematology does best in these situations such as these- order a repeat bone marrow, a prospect that frightened our patient enormously. Her protest was staunch and her argument was rather compelling- how was it that the first bone marrow and a plethora of tests done previously not helped in finding out a diagnosis so far?
This is just one out of the many patients in Internal Medicine who undergo lengthy testing in order to reach a diagnosis. Now, any tests that are performed can only be interpreted correctly in the back drop of a proper history and examination. Somewhere along the years while there were searches made and advancements done in laboratory workup and radiological investigations, internal medicine just lost its touch. What is ironic is the fact that while we have many more health conditions that are recognized now more than ever, we are often discharging patients home with the diagnosis on discharge often being idiopathic. We know from the tests that a patient has chronic kidney disease… there is no mention of what it was or what caused it. Many patients just lose faith in ever finding their diagnosis and eventually in finding a physician they can trust.
The old connoisseurs of medicine always bore that no amount of laboratory or radiologic investigation could ever trump a good history and examination, and I whole-heartedly agree, audacious as it may be to entertain this notion in an age in which medicine is supposed to be efficient and business savvy.
When tests are given precedence over clinical evaluation there are developments of unexpected results that can further add to diagnostic uncertainty and lead to patients being investigated or treated overtly
Taking a careful history and performing a thorough physical examination are the hallmarks of the good internist. Patient-centered care is associated with not only positive health outcomes, but also wiser use of resources targeted towards the diagnosis that one is thinking of based on a good history and examination . May we all realize this and become the internists our patients deserve.
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