“Take a risk”



Indexing Title: JGGuerra’s Medical Anecdotal Report (07-08)

 

MAR Title: Sharing Patient Management Process

 

Date of Medical Observation: July, 2007

 

Narration:

 

A middle-aged woman was referred to our department for evaluation of anterior neck mass. I happened to be the resident in charge at the OPD during the said referral. The junior resident of the referring department personally endorsed to me the patient as a case of a Nodular Non Toxic Goiter, TC Thyroiditis. I received the chart and noted her diagnosis and some battery of work ups, including blood count and thyroid function tests. With a polite gesture, I even explained to her our department’s protocol regarding the rational use of paraclinical procedure for thyroid patient in which more or less she agreed.

 

The resident accompanied me to the examining room to evaluate the patient. As I was approaching her, I noticed an anterior neck mass that I am quite sure that is not even thyroid in origin. But even before I lay my hands to examine her, the resident blurted out, “Mommy, si Dr. Guerra po, taga Surgery Siya po ang mag oopera sa thyroid nyo.” I was surprised. She already primed the patient for operation prior to my evaluation.

 

When I examined her, I palpated an anterior neck mass, about 4x3cm in size, fluctuant, subcutaneous in origin, with cardinal signs of inflammation and not even moves with deglutition. This is plain and simple subcutaneous abscess misdiagnosed as goiter. I did a needle evaluation and aspirated purulent fluid.

 

How am I going to deal with her misdiagnosis?  How am I going to explain to the patient her change of management?

 

After my evaluation, I asked the resident to come with me and discuss the case. I gave her a crash course on our patient management process.

 

After our discussion, we explained to the patient our final management of the case.

 

Insight (Physical, Psychosocial, Ethical) (Discovery, Stimulus, Reinforcements)

 

I have two issues in my MAR. First, how to deal with a colleague’s misdiagnosis and second how to help them lessen misdiagnosis by introducing and sharing to them the beauty of our Patient Management Process.

 

For the first concern, always maintain an open communication between you and the referring physician. When a misdiagnosis happened, try to resolve the issue between yourselves and try to arrive at a  decision that will not put into jeopardy your colleague’s refutation. Once final diagnosis is achieved, explain to the patient the change of management in a manner that she will not loss her trust to the attending doctor.

 

 

Secondly, in every physician’s attempt to manage a case, there are times that we cannot achieve a high certainty of coming up with a sure diagnosis. What is important is we rationalize every decision we made in treating our patient. It is very unfortunate that during med school, we were not taught of a system that will make our life easy as a practicing doctor. We were not aware that there is a process just needing to be introduced to every area of specialty that will perhaps shed light to the existing clouded approached in patient’s management. I think it is high time to give other department’s a copy of our patient management process. Better way is to introduce it as a course in physical diagnosis in med curriculum.

 

 

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