When identifying a disease as part of a rule-out list, charting what to look for may help avoid trouble down the road.
A 30-year-old obese woman visited the emergency room complaining of vaginal bleeding as well as numbness in her legs that was causing her to fall. The patient underwent a lumbar MRI and was admitted.
The next day, Dr. FP, a family practitioner, evaluated the women and ordered gynecologic and neurologic consultations. The MRI showed mild degenerative disc disease, but no evidence of significant stenosis. The gynecologist prescribed Flagyl for vaginitis.
Dr. N, the neurologist, charted numbness and tingling in the patient’s hands and feet for the past five days. Dr. N noted a “stocking & glove” distribution and a decreased deep tendon reflex. Dr. N’s initial impression was peripheral neuropathy and he prescribed Ativan and Neurontin.
He also ordered sed rate, antibody, and thyroid tests. When Dr. N saw the patient the next day, he noted persistent numbness and tingling in her hands, feet, and chest, extending to the legs. At that time, Dr. N’s impression was lumbar spondylosis and his plan was to continue the Neurontin. On Dr. FP’s referral, the patient saw an orthopedist who, while ordering a thoracic MRI for possible disk herniation, also noted that the “bilateral numbness and lack of any significant history of back pain or trauma also suggest a peripheral neuropathy, perhaps Guillain-Barré syndrome.”
When Dr. N saw the patient the next evening, the patient complained of pain in her lower back and “pins and needles” in her lower legs up to the breast level. The patient still had deep tendon reflexes and a downward toe sign. Dr. N raised the question of hysterical conversion reaction and noted to rule out thoracic cord lesion and transverse myelitis. Dr. N doubted Guillain-Barré syndrome and continued the Neurontin. In a consultation the next day, a spinal surgeon considered the thoracic MRI negative and commented that an elevated sed rate was possibly caused by the patient’s vaginitis.
On his next visit with the patient, Dr. N’s impression was peripheral neuropathy vs. hysterical conversion; rule out Guillain-Barré syndrome “(doubt)”; and rule out cervical spine compression, “also doubtful.” Dr. N recommended a cervical MRI and continued Neurontin.
The next day, the patient was able to move both legs but still complained of pain in her legs, back, and neck. Dr. N charted stocking/glove numbness up to the chest. During the visit, the patient mentioned the possibility of a surgical weight reduction procedure, such as stapling or a lap band. Dr. N continued the Neurontin and also ordered Cymbalta. Dr. FP ordered a psychiatric evaluation.
By the next day, the MRI revealed a left disc protrusion at C6-7 causing a mild cord deformity. Dr. N noted the possibility of fibromyalgia but again doubted Guillain-Barré syndrome, noting the patient’s dominant symptom being pain. He recommended continuing the Cymbalta and that discharge planning should begin.
The psychiatrist’s evaluation the next day diagnosed a somatic disorder. Later that day, Dr. FP indicated the patient could be discharged with follow-up by the patient’s family doctor.
Ten days later, the woman went to the county emergency room with numbness and tingling. A lumbar puncture revealed a protein level of 531 (normal 15-40). After an MRI, the patient was diagnosed with Guillain-Barré syndrome and underwent IV treatment and rehabilitation.
The woman later sued Dr. N for failing to order proper tests for Guillain-Barré syndrome. The parties resolved the dispute informally.
Physician charting is not only for the benefit of a patient’s other health care providers. A discipline of charting why a certain differential diagnosis is doubtful while also writing down what developing conditions would change that outlook can help the physician avoid the need to rely on just memory when considering what steps to take next.
Author Gordon Ownby is General Counsel for the Cooperative of American Physicians, Inc. (CAP).
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