nos-trum. pronunciation: \nos'-trum\. noun. Etymology: Latin, neuter of noster our, ours.
1. a medicine of secret composition recommended by its preparer but usually without scientific proof of its effectiveness.
2. a usually questionable remedy or scheme.
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Tuesday, June 15, 2010

Can Every Patient Be Diagnosed?

Good subject for a research study:  What percent of people think health issues can always be diagnosed?

I say this because it's my impression that patients assume that every health problem fits into a diagnosis...or they haven't ever thought about it.  My guess is the research result would be close to 100%.

I started thinking about this while reading one of those newspaper columns that specializes in telling stories about patients who went through hell, while a long line of doctors tried every test and treatment in the book to figure out how to help them.

The caricature of this kind of newspaper column finds our exhausted, confused, and angry patient visiting that last physician who says, "You know, I think I know what's going on here."   And the clouds part, a ray of sunshine bursts through, and the road to health and wellness is revealed.

OK, so that was hyperbole.  But, you know what I mean.  These stories are told for their emotional engagement.  It's a modern syndrome that people need to view and feel the emotional experiences of others.

But the psychology of living "virtually" through others is not what interested me.

What did was the original question:  does everything have a diagnosis? 

First, let's define what I'm NOT talking about:
1. Those situations where it's too early to make a diagnosis.  I've treated hundreds of people with abdominal pain where the symptoms, exam, and testing just don't add up to appendicitis...yet.  It can take 12 to 24 hours (rarely more) for someone with this symptom to develop the focal tenderness, rebound, elevated white blood cell count, etc, that makes the diagnosis certain enough to warrant doing surgery.  The same thing occurs with ear aches.  Signs of middle ear infection can lag 24 hours behind the onset of pain.  Lastly, I've seen patients where it took years for the signs and symptoms to solidify around a specific diagnosis.
2.  Those situations where the diagnosis is one of "exclusion."  Simply put, this is where there ARE no signs or tests that are specific to a disease (By contrast there ae diseases that have one test that tells all:  like a positive throat culture for strep).  Under these circumstances, doctors "exclude" everything else it could be by a process of elimination, hoping that only one possibility will remain.  This situation is very frustrating for patients.  Multiple sclerosis is commonly like this:  a spinal tap is positive 90% of the time, but is not specific to MS.  Other examples of diagnosis of exclusion:  Bell's palsy and irritable bowel syndrome.
3.  Those situations where the symptoms are too broad, and the doctor didn't go far enough in testing, at least initially.  Yes, every headache could be a brain tumor, but you don't do an MRI on every headache.  These cases sort themselves out by therapeutic trial, further testing, or the symptoms specific to a diagnosis become more prominent over time.
4.  Those situations where the patient conceals or de-emphasizes certain symptoms.  This happens frequently; people either don't want to admit to an embarrassing symptom or they've cloned in on a diagnostic belief that is misleading.
5.  Those situations where the patient has symptoms that are confusing, implausible or contradictory.  I once had a patient who said the anthrax shot caused vomiting that was fluorescent.  If true, that would be the first time in human history.  Another possibility is that patient whose problem involves delusional, hallucinatory, or chaotic thinking.

I could probably go on, but I'm narrowing things down to the barest minimum:  that health problem where nothing ever adds up.  Does this occur?

I read a population study that claimed 3% of patients, at any given time, have an undiagnosable problem.  I'm not sure I buy that it's that high.  I don't think they excluded all the situations I listed above.

That's about as far as we can go.  My opinion:  with perfect knowledge, everything has a cause (= diagnosis).  But contrary to popular belief medicine is still an art.  There's a boatload of science, but some things about the human condition are still a mystery.

In the real world (not the newspaper "virtual" world), to those who think that every symptom can match to a disease, and every disease a treatment, it just aint so.

Doc D

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