D.I.C.C

1. D.I.C.C

2. D.I.C.C • DIAGNOSIS IN CLINICAL CONTEXTS (THOSE WHO ARE SAD AT THE LOSS OF DERMATOLOGY FEAR NOT THIS NOBLE TOPIC WILL RETURN LATER IN THE YEAR)

3. AIMS AND OBJECTIVES • To consider diagnostic certainty • Think about the impact of a diagnosis on a patient • Consider the understanding a patient has of a diagnosis • Diagnosis in a medico legal context • Consume cake and tea

4. ARE YOU WELL? • What symptoms do each of has that could be shaped to fit a diagnosis • Who in the room has the most (and is the rest of the group surprised?)

5. Case History • 62y female • Type 2 Diabetic, HTN, Neuropathy, background retinopathy, RTKR • 124kg BMI40+ • Meds : insulin, ppi, bendroflumethiazide, losartan. • 2008 – chest pain – AE – d/c no cause found – no treatment given • 2009 – chest pain – AE – 4days later d/c – ACS – meds started.

6. Case History • Diagnosis – ACS • 1/52 tight central crushing chest pain, intermittent, exertional relieved by rest • Trop<0.01. • ETT – lasted 6mins had to stop due to severe chest pain. Minimal ST changes during test, 1mm depression in inferior leads in recovery. • GP F/U – “If has further chest pain to seek medical advice, OPA 6-8/52” • Started on: Atenolol, ramapril, ISMN, gtn - but not supplied.

7. Case History • Who thinks the diagnosis is correct? • If you were the cardiologist would you have done the same? • How useful are the test results, how useful is the history? • Whatever course of action – why did you choose that path? • What would you tell the patient?

8. Cardiologist View Point • What is ACS? • Includes unstable angina, NSTEMI and STEMI • Unstable angina: Unstable angina is defined as recurrent episodes of angina on minimal effort or at rest. In unstable angina (and non-Q wave infarction) the ECG typically shows T wave inversion or ST segment depression - however the ECG may be normal if some time has elapsed since the last episode of pain

9. Cardiology View Point • Can a diagnosis of ACS be made if a case does not fit this definition? • No it has to fit • Is an ETT a useful diagnostic tool? • No more for risk stratification – sensitivity and specificity if good hx up to 80% but falls rapidly if hx less convincing. Low probability cases consider CT angiogram, dobutamine stress echo and radio isotope scans.

10. Cardiology View Point • Can a fit and healthy individual induce ST depression on extreme exercise. • No. Only seen in SVT 220+. • Is ETT less reliable for women? • Yes. Syndrome X. False + more common.

11. Syndrome X • Cardiac syndrome X is a condition where patients have the pain of angina, but they do not have CAD. So even though patients with cardiac syndrome X have symptoms of CAD, the coronary arteries are clear of blockages. Cardiac syndrome X is more common in women, especially women who have gone through menopause. It is not life threatening and does not increase your risk of heart attack or CAD.

12. Cardiology View Point • If diagnosis is uncertain or a patient has risk factors and a good hx but the tests or inconclusive or negative how do you decide whether to offer life long treatment? • Could offer that cardiac cause is likely and treat, if uncertainty explain to pt and let them choose. If the pt desperately wants an answer consider coronary angiography (only seen 1 severe complication in 30years). Remember the drugs do cause SE the patients often don’t report.

13. Cardiology View Point • Do you worry especially in borderline cases if a diagnosis will have a negative impact on a patients life? • Some people can’t live with uncertainty, imagine being told you might or might not have a heart attack in the next 5 years – even less helpful! • How accurately can you diagnose the cause of chest pain? • Physician dependant – some are more aggressive in seeking the diagnosis

14. Cardiology View Point • In obese patients with ACS/IHD/angina considering drug treatment vs weight loss which is the most likely to reduce morbidity and mortality? • Didn’t commit but said both are important don’t forget statins are thought to have some form of anti-inflammatory property that reduces mortality in short term. Thinks start meds get pts who smoke to stop even if it means gaining weight then tackle weight as it will help reduce other risk factors caused by it.

15. Confused?? • Now what do you think about the diagnosis and treatment of our case? • Lets hear the notes of the GP consultations prior to our patients admission….

16. Who have we forgotten? • Ah patient!!! Lets give them a call and see what they have to say about all this! ….

17. What can we learn from this? • Diagnosis can be uncertain and incorrect. • Things don’t fit as neatly into boxes as we’d like • The patient experience of a diagnosis can be rather different to what we perceive. • Diagnosing and living with uncertainty can have a significant impact on a patients life. • I think how well we communicate with and support our patients through these grey areas may have significant positive impacts on their quality of life.

18. If you read one thing all year… • Iona Heath – The price of wishful thinking • Having good clinical knowledge and skills is required to be a truly good GP I believe the concepts in this article although simple are vital.

19. A final thought • I know that most men, including those at ease with problems of the greatest complexity, can seldom accept even the simplest and most obvious truth if it be such as would oblige them to admit the falsity of conclusions which they have delighted in explaining to colleagues, which they have proudly taught to others, and which they have woven, thread by thread, into the fabric of their lives.Leo TolstoyRussian mystic & novelist (1828 - 1910)

20. AND NOW FOR SOMETHING COMPLETELY DIFFERENT