Monday, 30 March 2009

The Dangers of Over-Reliance on Radiology than Patients Symptoms and Signs

Dear Bloggers

Sorry I have not been writing recently. I have been so busy, it has been difficult to collect my thoughts to put down online for you.

What I would like to discuss today, is the danger of relying on radiology rather than patient's symptoms and signs. Over time, I have heard of several cases, particularly involving the elderly, who have been admitted to various hospitals with pain or non-specific symptoms. The history and physical exams may not have been taken in detail and the patient then undergoes selected lab tests and radiological investigations which are deemed 'normal'. In view of the disparity of symptoms to scans, the patients have on occasion, been sent home.

In one of these anonymised cases a patient had severe abdominal pain of acute onset. The physical examination revealed some non-specific abdominal tenderness but no rebound or guarding with normal bowel sounds. A rectal examination was not performed but instead an abdominal Xray was done which showed loading of the colon with stool. The patient was reassured that the symptoms were purely related to constipation and he was sent home. However, the patient's pain was unrelenting and he re-presented to the hospital. After further workup, a contrast CT was performed which revealed splenic infarction.

A further anonymised case was of a female with lower back pain who had developed fever. She presented to a local hospital. The patient's pain was severe but was non-specific except its location was in the lower back. Movement made the pain worse. Straight leg raising had not been performed but application of pressure over the spine did not worsen the pain. Plain radiographs were taken but no abnormalities were seen. Urine examination was normal. The patient was considered to have non-specific musculoskeletal pain and was discharged home. This patient re-presented to the hospital and a further workup was instigated.

Blood cultures grew streptococcus spp in four culture bottles. Echocardiogram (trans-thoracic) was normal. CT and MRI scans of the back were normal.

However, the scans were repeated after several days which then revealed osteomyelitis. Thankfully, the patient had already been commenced on appropriate antibiotic therapy.

In all the above cases, the patients were seen by physicians who lacked experience and who relied on lab data and radiology to make their decisions. The histories in both cases involved severe pain but such symptoms were seemingly not appreciated.

Pain is not something that should be accepted as normal in the elderly. Pain should always be taken seriously as it is the patient telling us that there IS a problem which therefore, needs to be fully investigated.

Acute onset of pain is far more relevant diagnostically than chronic pain that waxes and wanes. It is a serious warning sign. For example, fever and lower back pain should immediately make the physician think of the serious causes of these symptoms that should not be missed, which include:
  • Osteomyelitis
  • Discitis
  • Psoas abscess (sometimes bilateral)
  • Multiple myeloma
  • Paravertebral abscess
  • Pyelonephritis (sometimes bilateral)
These causes must be excluded before even considering sending a patient home.

In these two cases, the symptoms of pain were severe but the causes of which were not supported by basic radiology. Just because basic radiology looks normal does not mean that there is not a serious problem. It does not mean that we can safely discharge a patient. Quite the contrary. Elderly patients are sometimes difficult to diagnose and have a lower threshold for admission to hospital and especially as they can deteriorate rapidly.

Moreover, the pain itself needs to be addressed and not considered as inconsequential. It is very important. Doctors need to adopt a more holistic and humanitarian approach to patients rather than just considering the pathophysiological causes. The latter is academic but forgets that this is happening to a patient - a human being. Patients should receive analgesia as soon as possible on entry to a hospital for severe pain e.g. morphine in AMI, and should never be kept in pain for fear that the symptoms might resolve and therefore make the condition undiagnosable. The approach of withholding pain relief is not relevant to modern practise and is inhumane to patients.

Please do not think that the use of opiate medication for severe pain in the acute situation is going to lead to addiction. Chronic use can lead to addiction but again, that should not be a primary reason for not using it - pain control should be the ultimate goal. Patients with end-stage disease e.g. disseminated cancer often benefit from good pain relief. It does not mean they will become 'addicts'.

In these anecdotal 'grey cases' the patients need to be hospitalised without equivocation. They need adequate pain relief. Believe what they tell you. They are telling you the diagnosis. Even if the basic radiology is normal, take more history to try and elucidate the cause. Re-examine. Ask your senior physician to review the patient for a second opinion. Perform the advanced radiology e.g. CT or MRI. Get an experienced doctor to review the scans or even better, a radiologist.
Don't send the patient home if the diagnosis is unclear. Certain disorders e.g. abscess formation, takes time to fully manifest and an initial scan can be normal.
Believe in the patients symptoms and signs. Don't be fooled by a normal scan. Scans can change over time and reveal that the patient has been telling you the truth all of the time.

Bearing that in mind, many of you are probably thinking 'But if I admit every patient I see (because I have no idea of the diagnosis) then my boss is going to get really angry with me for all the extra work I have created'. Don't worry about your angry boss. Worry about the patients; they come first. It is better to have patients in hospital under investigations and treatment for potentially severe problems rather than inappropriately labelling them with constipation or simple back pain and sending them home. That does not help the patient, and also causes detriment to you too.

Moreover, believe in yourself and your learned skills. When I was a junior doctor, only 3 months out of medical school, a patient with decompensated liver disease developed a fever and back pain over night. The patient was septic with a high fever, tachycardia and low blood pressure. His lower back was tender to palpation although not over the costovertebral angles (loin region). Urine examination revealed evidence of infection. I suspected a UTI with secondary haematogenous osteomyelitis / discitis.

On the morning ward round, my boss (a most distinguished doctor in a high level university hospital) listened to the night's events and said that I must be mistaken - it was just a UTI. However, despite several days of intravenous cefuroxime (2nd generation cepahalosporin) the sepsis did not abate and the back pain worsened.

Another doctor on the team also considered that ruling out a more serious cause was warranted and so a CT scan was arranged - it confirmed the discitis.

Take Home Message

  • If you don't know what is going on with a patient who is experiencing severe pain and / or non-specific symptoms that make diagnosis difficult (and it is of concern to you as a doctor, the patient or the family) please do not send the patient home expeditiously.
  • It is better to keep the patient in hospital for observation and further studies
  • Avoid Ageism
  • Be humane and treat pain. Your patients will appreciate you very much.
  • Remember, that diseases take time to manifest. Repeat history taking, physical examination and advanced scans can reveal the diagnosis in the end.
  • Always inform your senior doctor if you have a difficult to manage patient. Their experience of similar cases can provide a wealth of knowledge on how to make the diagnosis and manage the patient safely and effectively.
  • The time honoured adage of 'All things reveal themselves in time' is perhaps a fitting comment for such patients. However, you must be certain to exclude serious pathology quickly but also appropriately consider those disorders that may take time to manifest. Hence, in this latter idea, taking the 'wait and see' approach is far better than the 'bye bye' approach.
  • Believe in yourself and your skills.

Please consider.....