The Slim Book of Health Pearls: Challenging Diagnoses. Sheldon Cohen
THE SLIM BOOK OF HEALTH PEARLS
CHALLENGING
DIAGNOSES
Sheldon Cohen M.D. FACP
Copyright 2013 Sheldon Cohen,
All rights reserved.
Published in eBook format by eBookIt.com
ISBN-13: 978-1-4566-1551-2
No part of this book may be reproduced in any form or by any electronic or mechanical means including information storage and retrieval systems, without permission in writing from the author. The only exception is by a reviewer, who may quote short excerpts in a review.
A graduate of the University of Illinois College of Medicine, Sheldon Cohen has practiced internal medicine, served as a medical director of the Alexian Brother’s Medical Center in Northwest Suburban Chicago, and served as the medical director of two managed care organizations: Cigna Health plan of Illinois and Humanicare Plus of Illinois. The author taught internal medicine and physical diagnosis to medical students from Loyola University Stritch School of Medicine and the Chicago Medical School. Recognizing the fact that busy physicians are pressed for time and thus often fail to capture a thorough medical history, the author perfected one of the first computerized medical history systems for private practice and wrote a paper on his experience with 1500 patients who utilized the system. This was one of the early efforts in promoting electronic health records, a work in progress to this day. Serving as a consultant for Joint Commission Resources of the Joint Commission on Accreditation of Healthcare Organizations, the author did quality consultations at hospitals in the United States, Rio de Janeiro, Brazil, Copenhagen, Denmark, and served as a consultant to the Ministry of Health in Ukraine, assisting them in the development of a hospital accrediting body. The author lectures to lay audiences on Risk Factor Analysis, Early Detection and Prevention, Symptoms Never to Ignore, The Prevention of Medical Errors, How to Take Charge of Your Own Healthcare, Hormones Nerves and stress, and other topics of a medical nature.
Dr. Cohen is the author of twenty books.
Dedicated to
Betty
Gail and Paul
XO
ALSO BY SHELDON COHEN
A Jewish Journey
A Jewish Story
The Twins
Brainstorm
Holy Warrior Trojan Horses
Revenge
Bad Blood
The Monster Within
The History of Physics from 2000BCE to 1945
World War IV: Militant Islam’s Struggle for World Control
Grandpa’s Story-Poems and Grandkids Illustrate It Yourself Book
The Coming Healthcare Revolution: Take Control of Your Health
The Making of a Physician
The Slim Book of health Pearls Series:
Am I at Risk? The patient’s Guide to Health Risk Factors
Hormones, Nerves and Stress
Man the Barricades: The Story of the Immune System
Symptoms Never to Ignore
The Complete Medical Examination
The Prevention of Medical Errors
The Perfect Prescription (with Megan Godwin)
PROLOGUE
Incorrect, delayed, or missed diagnoses have plagued physicians since the beginning of time. The result may be significant patient harm and medical resources wasted as the majority of all primary care physicians surveyed report that an average of five percent of their patients come under the category of “difficult to diagnose.” The more the experience of the physician, the less the diagnostic difficulty reported. As many as 20 percent of physicians report that inadequate knowledge was the main cognitive factor involved in failing to diagnose. Other factors include insufficient time to adequately reflect on diagnostically difficult patients, and inadequate time to acquire a careful medical history and perform a thorough physical examination; a situation which will only worsen as the primary care physician shortage is about to be compounded by an influx of patients due to the new Patient Protection and the Affordable Care Act, a bill signed into law to reform the countries healthcare (Obamacare).
This compounding of factors makes it more important than ever for patients to take the time to understand their own symptoms, assist in the zeroing in process of the diagnostic evaluation and collaborate fully with their physician in the sometime twists and turns leading to a final diagnosis. This intense exercise by both physician and patient alike will result in several different outcomes depending upon the complexity of the case:
•A correct diagnosis is established
•A single diagnosis is not established, but a differential diagnosis is. This is a number of plausible possibilities that each, in turn, require investigation to rule out or rule in
•An incorrect diagnosis has been established (misdiagnosis)
•No diagnosis has been made…no clue
•There is more than one diagnosis
So, as a prospective patient—and we all are at one time or another—it becomes more important than ever to be an assertive and collaborative patient, working in concert with the physician to arrive at, or on occasion, not arrive at a definite diagnosis.
Once this point has been reached, you as a patient are not finished. What the physician has done is carefully—you hope, made a list of all the diagnostic possibilities and ruled them out one by one until the final diagnosis is established. You need to be in on this process throughout, and when it has reached completion, or even during the process, you need to be constantly asking, “What else do we have to think about?” It is important that you have played a part in the process of elimination by being completely true with your medical facts, because incomplete or false statements can lead your physician down the wrong path, and ultimately lead to a wrong diagnosis.
This book will discuss illnesses difficult to diagnose. First among this category are autoimmune diseases, unrecognized as a medical entity until about sixty years ago. To better understand an autoimmune disease, it is essential to understand the concept of immunity, a subject for discussion now.
If you are blessed with sufficient body defenses to fight off invading infectious agents such as bacteria, viruses, fungi and parasites, you are said to have good immunity. Be thankful because there are some of us born with greatly diminished immune ability; or even born without any immunity. Anyone in this category is said to be immunocompromised. This threatening condition makes one extremely vulnerable to invasion by pathogens (an infectious agent that causes disease or illness to its host). The great majority of healthy persons with a well-functioning immune system will have no difficulty neutralizing invading pathogens before they can cause disease, but those whose immune system is compromised may fall victim to the invading pathogen’s effects—including death.
Again, in a book with the title CHALLENGING DIAGNOSES, why do I start with the subject of immunity? Because, as it turns out, most challenging diagnoses patients—the bane of primary care physicians and patients—are those who have developed an illness brought about by a malfunctioning immune system. So, if the readers are to have any hope of understanding what may be ailing them, then they must have a basic understanding of the mechanism that is causing their condition