Monday, November 24, 2008

Why These were Missed?

I've seen a few cases over the last week and I really have some thoughts to share:

Case 1

A 70 year-old man complained of progressive abdominal distension and went to a hospital. He was told to have "angin" in the abdomen and was discharged with Syr MMT (antacid).

Case 2

A 8 year-old boy complained of "abdominal discomfort". He was told to have "gastritis" and was discharged with Syr MMT, too.

Case 3

A 50 year-old man complained of 2-month history of cough and generalized lethargy and reduced appetite. He went to several clinics, was given reassurance and multiple courses of multi-vitamins and cough mixtures.

Simple cases? Let me tell you what happened in the next half of the stories. I was really, really shocked to find out that:

Case 1

The abdomen is really distended and instead of "angin" inside, it's gross ascites! Baseline blood tests showed anemia with reversed alb:glob ratio - he was then admitted to check for the cause of paraproteinemia - and it then turned out to be multiple myeloma.

Case 2

8 year-old boy with "gastritis"? This is really not a good diagnosis that you give to a young boy. The abdominal discomfort was actually due to large hepatosplenomegaly, and also generalized lymphadenopathy was noted. The FBC showed pancytopenia. He's suspected to have hematological malignancy.

Case 3

Looking at the chest Xray, I don't think I have to say much:

A huge suspicious mass at the right upper zone. Need to rule out lung tumour.

What's happening?
Honestly, to pick up the gross ascites and the enlarged liver and spleen is nothing great. I think even a medical student can detect them. Maybe what they needed is, a person who REALLY examined them.

The moral of the stories is:
1. Eventhough the clinic/ outpatient is always busy, pls really spend some times to see the patients. Shorten the time by focal history and examination, but never "just symptomatic treatment".

2. Pick up the "alarm symptoms" - If an elderly complained of lethargy and poor appetite, "Multi-vitamin" is not the first-line treatment - Investigate properly!

3. If a patient tells you that his symptoms persist despite multiple courses of treatment, an alternative diagnosis should be strongly considered!

4. If you're not sure of something, consult the experts. You might get some unpleasant responses, but it benefits the patients!

At the end of the day, just ask yourself:

Are the patients happy with the diagnosis and the treatment?
Have you done sufficiently for the patients?

11 comments:

confessions of a medical student said...

it scares me... life after graduation... it scares me even more than exams.. it scares me if i had not studied enough, and having enough knowledge and skills... when we miss something, or make mistakes, patients suffer, their quality of life affected... sigh..

have to work harder..

Jason said...

totally agreed what u said.

need to work harder, for patients, for their health.

Zzzyun said...

it scares me too.

that i miss smtg crucial when i start work, just becoz i wasnt observant enough, or didnt study enough..

i dont want to cause misery to someone else becoz of my own mistakes!

Jing said...

study wont make u pick up the important things.

imho, it is how well u want to treat your patient or u just do clinics for the sake of doing it? mmmm... its all up to u...

even ur a mediocre clinician (no clues whatsoeva with the patient's complaints), a simple routine physical examination would detect any of the above abnormalities.

rite? just my thoughts...

mich said...

scary...
if i tend to applied into my course...
can sentence ppl to death one...

peanut said...

but it is quite hard for me as a student to tell the job is going to be my life long passion or just dreaded responsibility.

am sure that people had always started med school with a noble vision and passionate heart but somewhere down the road things changed?

Darren Lee said...

Yo dear frens, this is not meant to be a "scary" post la hehe..take it easy. I guess if you go with the "moral of the story" then things won't go too wrong..

I'm sure you all can do well! No doubt!=)

Yew TW said...

no one is perfect - noone is free from mistakes. but need to do our best lo.

Darren Lee said...

Yew: Yes it's the golden rule - no one can be free of mistakes! Must try to learn the most from it, and do our best not to repeat them..

- yuhhui - said...

Diagnosing patients require lots of patients. And it's not easy... hehe.. be like Dr House ! =D

confessions of a medical student said...

ophs... sorry for starting the 'scary' emotion.. -was in the mist of exams.. *take back*

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