Russian Case Study- complex patient - complications caused by delays in timely coordination between experts
CASE STUDIES 2001 & 2005
ACCESS TO EXPERT-BY-PHONE EXAMPLES
Timely Integrated Intervention-Using Medical Phone Answers Now Model When possible-every person with a chronic, complex, costly or unclear problem should have a prompt team phone conference with five specialists.
If practical -every person would work with their significant other to answer the 5 question tool and then go thru a progressive triage followed with conferencing with team who will have continuity with person. The team includes team (representatives) of the 5 questions: the team may have varying backgrounds ex: nurse, psychologist, social worker, orthopedist, spiritual advisor. or another team: chiropractor, nurse, physical therapist, therapist, teacher.
Initially the nurse or first person taking phone call at a call center ; or the examiner at first office- benefits from a multi-disciplinary approach to challenge and interventions to be considered and followed up on.
Below are several "Quick and Dirty Summaries" of how an expert can by phone come to a decision which has a high probability of being correct. The following examples illustrate how a low cost "screening approach" can be used to help the less experienced find the appropriate expert efficiently.
CASE 1: A young woman, age 20, was seen for psychotherapy for 15 months after a number of general medical and eye examinations. The initial complaint was that she saw double and there were no findings. She also was a bit hysterical or rather dramatic in her presentation. She also said occasionally she felt a little weak but on gross examination had no findings. It turned out that she had a mild initial onset of myasthenia gravis which was diagnosed for a long time as hysteria. She was rather frustrated with the psychotherapy as was her psychiatrist. It was her third psychiatrist that finally made the diagnosis. This again could have been picked up with a good telephone screening protocol. She responded to oral medication.
Case 1 Explanation
Patient with friend or at first examination by health provider would be screened with the five question tool.
Do you have any challenges in following areas?
1) Physical --yes-- double vision at times------------- A nurse is on team----This triggers call to eye doctor
2)Psychological -yes--dramatic in describing symtoms-.......This triggers call to psychologist
3)Social- no- .......Social worker on Team
4)Work, school --no ........Chiropractor on Team
5) What's most important to you?-- being cured of my double vision and weakness -This triggers call to neurologist
CASE 2: I was phoned about this lady with progressive depression over three years and slowly evolving trouble with memory, calculations and other cognitive difficulties. After 20 years history of multiple problems and evaluations, a tentative diagnosis of Vitamin B-12 deficiency secondary to malabsorption was made on the phone. Red flags triggering this diagnosis were: 1) gastrectomy; 2) trouble with memory; 3) non-responsive (progressive) depression. She was asked to come in for a neurological evaluation and review of records. Nothing new was found. I ordered a Vitamin B-12 blood level. This indicated an abnormally low B-12 level. Treatment was started with Vitamin B-12 injections. She began to improve with respect to her memory and cognitive difficulties after one week of the injections. By the end of one month, her depression had improved, as well as her general functioning. A reevaluation showed continuing improvement at four months after treatment was started. She made significant improvement which she maintained. She returned to almost her normal self with no depression, but with a small residua of cognitive function deficit.
Our model's approach: With a screening history which could easily be done using a basic history questionnaire three years before or upon the first onset of symptoms/problems with memory and depression, red flags would have been triggered by: 1) gastrectomy; 2) trouble with memory; 3) non-responsive (progressive) depression.
An intermediate level expert/screener and decision making tools like a paper algorithm would immediately trigger referral of the history to a neurologist and psychiatrist. Vitamin B-12 blood levels would be part of a simple, immediate, recommended screen - certainly before magnetic resonance imaging of the head, psychological evaluation, psychotherapy and other treatments this lady had received without benefit.
CASE 3: Another patient, a child age 12, moved from a small farm town to a larger city in California. A couple of months later a teacher said he was not doing good work and other teachers likewise said that his behavior and work had gone down. After lots of psychological tests, psychotherapy and blood tests, it finally turned out that he had been exposed to lots of agricultural sprays in the farm area where he lived, resulting in a toxic encephalitis.
CASE 4: This 64-year old lady has a complex history with problems crossing four specialties (Internal Medicine, Psychiatry, Neurology, Neurosurgery). The semi-acute and chronic problems were present for six years before she was referred to me. With our phone/FAX model, at least three years of grief and unneeded, ineffective and costly medical treatment could have been prevented. She was the happily married mother of an adult child when her husband died. He was 68 and she was 58. Preceding this, she had a mildly elevated blood pressure that was being easily controlled with medication. After her husband died, she developed a depression that improved with a combination of eight visits to a psychiatrist and some medication over the course of ten months. At that point, she developed a little trouble with her memory and minimal weakness over the left side of her body, and a stroke was diagnosed. This was thought due to a small blood vessel clot in her brain. The weakness disappeared and the depression appeared to get better or worse from day to day with no clear reasons. Her daughter and five year old grandchild had moved from the family's home area of Philadelphia, PA to San Francisco six months before the stroke and recurrent depression. This move was thought to be part of the explanation for the stroke and recurrent depression. Her daughter in San Francisco invited her to move out and join her, which she did. However, after a few months in San Francisco, her depression continued to get better or worse every few days for no reason. She saw a good, sophisticated internist who realized that the picture was not typical of depression, high blood pressure or stroke. He referred her to me for neurological consultation, and with the history, it was apparent that she either had a very unusual type of progressive stroke - not likely because of her significant areas of improvement and no new abnormal findings on her examination, or a brain tumor. She had a benign brain tumor - meningioma that was successfully surgically removed. After this, her depression cleared, and the fluctuations in her blood pressure improved. She did well after this.
Our Model's Approach: Even with the complex problem, a good initial screening questionnaire in this type of situation would highlight the issue of blood pressure problems and depression. This leads to a secondary specialized questionnaire or quick phone screen with a neurologist and psychiatrist. The atypical pattern of the depression associated with memory problems would then early on lead to a recommendation for a CAT scan (or MRI) of her head, and an electroencephalogram for this lady. This would identify the presence of a tumor three years earlier. The key here is the pattern of symptom presentation. As we proceed, more of the descriptions of clinical syndromes will be converted to trend charts and graphic presentations. This conversion can be expedited by experts in individual fields involved. This permits more utilization of automated technology procedures.
CASE 5: This 15 year old girl had been in two psychiatric hospitals and 2 inpatient drug rehabilitation programs. This for problems of excessive drug use, including alcohol and street drugs, smoking as well as having been pregnant once. Her parents had taken her to very many doctors out of the hospital as well as in the hospital. It turned out that she had a brain stem astrocytoma- cancer of brain. This possibility had never been considered as a part of her problems. She had not had an EEG or neurological consult. Part of her behavior problems as well as part of her fainting, dizziness and other problems were associated with this tumor. Once again, she and the family on retrospective history, said that she at times was spacy, uncooperative, forgot things and had a lot of other problems which were all attributed to "behavior problems" resulting from her parents getting divorced. After a biopsy of the brain stem, she had radiation treatment and has done well enough to continue with special education and take care of her own needs. So far seems to be making fair progress .She has completed high school, is in college, works part time and is able to care for herself physically and has financial and emotional support from her family and treatment team. This is 5 years after surgery on her brain tumor.
CASE 6: A 14-year-old boy was seen by a number of ear, nose and throat specialists, psychiatrists, internists and family therapists over 15 months time. This was for headaches and dizziness and subsequently "uncooperative" behavior with his mother and grandmother. While on the phone with him, I discovered that there were times when he would lie on the floor and say he couldn't get up, and times when he would not respond and then get up. This was called being obstinate. We did an electroencephalogram on him and then subsequently an MRI revealed a pineal tumor. This situation had been associated with lots of grief for the family and guilt as the mother was blamed for his behavior. His pineal tumor symptoms were called a variety of psychiatric "things." He also had allergies which were a diverting issue for a long time. He had successful surgery and has since finished his bachelor's work at a University of California campus.
CASE 7: Another child with multiple behavior problems first seen at age 16 had been kicked out of many schools, in fights, lots of behavior problems, trouble with learning, antisocial behavior, drug substance abuse, etc. He had been in juvenile hall and was being considered a candidate for early placement in state prison as soon as he reached 18 because of increasing violent encounters. It turned out that he, in addition to having manic-depressive illness and allergies, had a history of head injuries and seizure disorder with poor impulse control and violent behavior. With treatment, the child did well in a residential treatment setting.
CASE 8: A lady, age 38, referred by the orthopedic clinic to neurology for evaluation of a painful neuropathy around her lateral malleolus which was thought to be secondary to a fracture. She had had three fractures associated with falls in the previous year--one clavicle, one arm as well as an ankle--and then it evolved that she had been diagnosed, at age 17, with seizures. She had stopped taking her medicine after years and then even given this history several months before to a medical resident but nothing had been done. The focus by the treating physician - including the orthopedist, had been on treating her fractures. Needless to say there were a considerable number of x-rays and surgical procedures provided at great cost and considerable distress to the patient. Much of this might have been avoided with a better coordinated diagnostic and tracking program.
CASE 9: A 50-year old lady who had been admitted to intensive care and coronary care units on three different occasions at a good hospital. She had reported feeling dizzy and having chest pressure. On evaluation on three different occasions by various medical, intensive care and coronary care specialists she was observed to be obese and mildly hypertensive but otherwise had no adequate explanation for her symptoms. In talking with her on the phone it turned out that in addition to her vague chest discomfort and dizziness she had also had some parasthesias of one arm associated with the situation and had a history of passing out several times with the dizziness. It turned out that she had major and clear-cut abnormalities on her electroencephalogram--partial seizure disorder--which caused both dizziness, chest parasthesias and faints. On the phone I was able to get more information about the dizziness and faints. I referred her for an electroencephalogram, and saw her subsequently for neurological consultation. There were no findings on the examination other than the history and the abnormal electroencephalogram. She has done well for many years taking an anti-convulsant--Tegretol. This lady had six months of grief, great concern, great expense to an insurance company and was unable to work effectively.
CASE 10: A lady was referred for unexplained abdominal pains and recurrent nausea. She had a laparotomy and then subsequently was admitted to a coronary care unit. One year later, a coronary angiography was done. It turned out that she had normal findings on all of these tests and likewise had complex partial seizures. Her vague chest pains and unexplained abdominal pains were an atypical expression of a partial seizure (partial convulsion).
CASE 11: A woman presented with recurrent abdominal cramps, nausea, vomiting and distress. She was followed for several years with a barium enema of her GI. It turned out she had several food allergies including allergy to lactose containing products.
All of these could have been diagnosed fairly promptly with the proper screening process including many of them with a phone screening integrated an approach as described.
2005 Case Studies
CASE 12: 26 year old successful, happy secretary complained of double vision and occasional weakness of 10 to 30 minutes Told by Dr that there was no physical basis-had hysteria and referred to psychiatrist who she saw 4 times in 2 months. Secretary did not believe Dr was correct. A second opinion identified a physical problem. Diagnosis Myasthenia gravis. Lesson: note score difference and note you should believe your own gut feelings and get second opinion. Some times need to go to another orbit of health practitioners.
CASE 13: 28 year old architect with Masters Degree and is working on Phd. Had bad concussion at work. After one month on return to school did well except on part time job had problems with spatial orientation in drafting job. Workers compensation evaluation by neuropsychologist, neurologist and psychiatrist reported no physical basis. Denied workers comp claim. Architect refused this denial and additional three psychological tests and detailed neurological exam and electroencephalogram identified subtle residual brain dysfunction. Lesson: Patient believe yourself. Do not accept diagnosis you do not think reasonable. Be alert to conflict of interests in examiners.
CASE 14: 18 year old with many recorded problems since age 6 with behavior, learning, law, periodic rage and fights, drug abuse and car theft documented. Details of many overlooked issues in his care and evaluation over many years to be discussed. Lesson: Do not attribute all of problems to initial complaint of learning problems-dyslexia, or behavior problem. More detailed case history to be discussed.
Case 15: Sudden deafness in 54 year old married postman .Sudden blindness in 14 year old Hispanic girl seen in emergency room on Saturday night. Evaluation and "miracle" cure with cause and approach to be detailed. Lesson: Sometimes a few timely questions can lead to cause and cure with brain power and minimal technology.
CASE 16: 60 year old woman professional with score of 1. Had fainting episodes and treatment in intensive care two times with no cause of fainting identified. later evaluation and a several questions identified cause and effective treatment. Her self scoring was 3 and the examiners was 1 . Lesson: Work on reasons for different scoring to get to the bottom of problem.
CASE 17: A boy and girl ages 11 and 9 will illustrate similar problem. One identified while playing baseball and the other playing with dolls with friend. Both have sudden observed change in behavior. Both scored self at 4 and family scored at 4 also. Lesson: These cases to be discussed and suggestions on how at home and with friends one can get better answers earlier and then go to "experts" when you may have answer or all the observations needed to get to solution and best prevention/treatment sooner.
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