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Shotgun Testing

Part of a resident’s job is to learn the ropes in preparing for independent practice. While you’re a resident, you get the benefit of having someone looking over your shoulder to critique you as you determine how you are going to manage patients.

I frequently tell residents that different attending physicians practice medicine in different ways. Some practice defensive medicine more than others, some prescribe antibiotics more than others and some work harder than others. The resident’s job is to figure out whose practice they are going to emulate when they begin practicing on their own.

That being said, I usually practice conservatively. I don’t tend to shotgun a lot of cases. When residents present cases to me, I make them give me a differential diagnosis and justify why they order the tests that they order. If they can’t justify why they’re doing the tests, then I won’t approve the tests.

A resident rotating on the first day in our emergency department presented a case to me and his comments made me think.

A woman in her 40’s came in complaining of tender lymph nodes to her neck for the previous 36 hours. That was it. She had pain in her neck when she turned her head to one side and thought she had cancer.

The resident ordered a CBC, comprehensive metabolic panel, cardiac enzymes, coags, chest x-ray, urinalysis, influenza swab, and strep test. He wanted to know whether I wanted to do a soft tissue x-ray of the neck or a CT scan of the neck.

“So what do you think is causing the swollen glands?”
“Maybe strep, maybe cancer.”
“Why the cardiac enzymes and coags?”
“If it is cancer and she needs surgery, the surgeons require a baseline.”
“Any other symptoms besides the swollen glands?”
“Why the urinalysis?”
“I figured they could do that while they’re getting the pregnancy test.”
“Why the pregnancy test?”
“She’s going to need x-rays, right?”
“We can’t do an abdominal shield?”
“Is a $200 flu swab going to be worthwhile?”
“It could cause the swollen glands.”
“In a patient with no fever, no cough, no pharyngitis, and the incidence of influenza sporadic according to the CDC?”
“Didn’t think of that.” He was obviously getting annoyed. “Fine. What do you want me to order?”
“Anything else on the physical exam?”
“Not really. No nodes anywhere else. No signs of infection.”
“Let’s go look.”

I’m typing this case up on the fly and was going to finish describing the interaction, but then I thought that maybe you all would like to take a crack at guessing what was causing the bilateral tender lymphadenopathy in the patient’s neck.

I’ll give you a couple of hints, since the diagnosis was rather obvious on examination and therefore I can’t tell you what the exam showed. First, the resident didn’t perform a good physical examination and didn’t take a good history. Both of those would have led to the correct diagnosis.

Remember, the nodes were bilateral and the diagnosis was obvious.

What do you think?

I’ll post the answer in the comments in a couple of days.

The answer is posted in the comments section.
The point of the post was not to belittle the resident, but was more to make a statement about how another resident felt that residency training was lacking.

Another resident in our program lamented that most of their didactic teaching doesn’t involve close physical examination or a thorough history any more. She felt that the overwhelming teaching points during the residency program were to perform procedures and to work up patient complaints to avoid being sued: Take the patient’s chief complaint, order tests that can rule out all the things that doctors commonly get sued over, and have them follow up with their family physician. You make the diagnosis – great. If not – that’s why they have family practitioners. Patients with high risk complaints and any risk factors for bad outcomes get admitted.

I actually got pegged as someone the residents like working with because I make them think about what they’re doing  – although the resident above avoided me the rest of the day.

If defensive medical practice is as entrenched in our residency programs as this resident seems to believe, our system will get worse, not better with health reform. More “insured” patients will be dumped into the system, health care access will become more disjointed, and patient will end up bouncing from emergency department to emergency department getting shotgun testing that will rule out remote life threats and protect the physicians from lawsuits but that will never really get to the bottom of the patient’s problems.

This patient probably would have had a high WBC count if labs were ordered. Maybe she would have been discharged on antibiotics and improved without making the diagnosis. The cost to the system for the proposed workup, though, would have been immense. Is this the way we want to spend our health care dollars?

Until we address the fear of malpractice that drives defensive medicine (and I’ll even cede that some of that fear is irrational), we’ll never reduce our healthcare spending.

No comments

  1. Obvious?


  2. Madrocketscientist


  3. Above, obviously. Strep pharyngitis? EBV/Mono pharyngitis? Using bleach to treat zits? (Yeah, seen it)

  4. Well, assuming that the physical and history really provide no other clues(and you already said they actually did) in the outpatient setting I would do no additional work up at all unless it worsened or did not resolve within a couple of weeks. Most likely there is a so far asymptomatic infection which will either declare itself or self-resolve. And if it doesn’t then you run the tests. Now this is all actually moot to the case in hand where there was an obvious diagnosis on history and exam according to you. And of course my scenario is outpatient management of an established patient. That is of course where this patient should have presented if she had one regardless of what the diagnosis ultimately is.

  5. Mono – kissing tonsils, fatigue, splenomegaly.
    Strep – Exudates.
    Apical Abscesses – Poor Dentition.
    HIV- Thrush.

  6. the lady felt the lymph nodes, then kept manipulating her neck because she was obsessed with the nodes. Treatment: stop fucking with your neck ;)

  7. Tonsilitis….or allergies.

  8. Cellulitis?

    Neck injury and not actually lymphadenopathy?

  9. I agree with Brighid. Mumps certainly sounds likely.

    But based on the fact the resident didn’t do a good examination or take a good history, I have to ask if this actually was bilateral LAD. Was it perhaps another neck structure – a big thyroid perhaps?

  10. Tooth infection?

  11. Well–no tonsils, bilateral tender nodes in a 40 year old woman.

    Causes of lymphadenopathy: 1. infection 2. malignancy. Now, there’s something you can SEE on physical exam.

    The pathologist in me wants to say things like Castleman’s DZ, or a Non-hodgkin’s lymphoma. As common things are common, and it can be seen–infected ear piercings.

  12. Inflammation from recent tongue piercing? Infection from tattoo?

    • That is to say, abscess as in a boil or carbuncle. Sometimes they don’t bulge out in the neck because they tend to expand into the fascial planes. So yeah, maybe community acquired MRSA? Boring, but way more common than ludwig’s.

  13. head lice. I’ve never seen them cause lymphadenopathy but a colleague did. And would definately be evident on exam.

  14. I knew someone who had swollen lymph nodes simply from having a bad case of scalp psoriasis… all hidden by hair.

    • OK, you’re close enough that I’ll give it to you. She had multiple infected wounds on her scalp that grew out methicillin sensitive staph aureus. They were just hidden by her hair, but were readily evident if the hair was parted.
      Now the history part – can you guess why she had the abscesses?
      Remember it is a middle aged female patient.

  15. I laughed pretty hard at that resident’s responses to your probings. It’s like the ping pong ball being thrown into a sea of mouse traps…run one test and have to run 10 more to check for complications of the 1st test.

    It’s not fair that we don’t get to “examine” the patient….my quick research shows that over 400 things can cause swollen lymph nodes. Since it’s probably nothing exotic like autoimmune, it’s either bacterial or viral. If its viral you can’t do anything anyways, and if it’s bacterial and swollen lymph nodes is the only symptom, then it’ll probably clear up on it’s own. So my ruling is do nothing except prescribe a placebo.

    Is it something stupid like the common cold and she just kept feeling her neck until she irritated the hell outta it?

    • Good reasoning, but see comment above. I posted it after your answer, so don’t anyone else give Anon a hard time about reading the comments.

  16. why in the heck wouldn’t she mention the festering wounds on her scalp during the HPI?

    was it from hair transplantation? or was she compulsively picking her dandruff?

  17. Hair dye? Extensions? Other hair related beauty treatments.

    Eeew! Lice! I’m itching now. I can handle just about anything, but lice makes me start scratching all over…

  18. I’m going with more self-inflicted. Meth user?

  19. Hmm.. since you suggested it was super obvious from the exam, is it possible that these weren’t lymph nodes at all and were infact the thyroid that you were able to palpate? Goiter?

  20. History was that the patient had used a new hair dye formulation several days before the nodes appeared. Appeared to be contact dermatitis to the scalp that became infected.
    She kept her hair pulled backwards in a pony tail and denied knowing that the sores on her scalp were even present. She never noticed the lice, either.
    She was given prescriptions for Keflex and Bactrim orally until culture results returned. We also gave her permethrin lotion for the lice, betamethasone lotion for her scalp and recommended Burows solution application. When we called her with the culture results, her scalp had improved and her neck wasn’t as sore.

  21. So if the intern had been allowed to order all those tests would the likely results point to the correct diagnosis, even a little?

  22. This is a great post! I think I’ll have to bring it to class one day as an example.

    In my medical program we do problem based learning (PBL) as the basis of our curriculum. This means that each week we are given a case where a patient presents (this is on paper, not human) with a chief complaint. As a group of 9 we tease out hypothesis (differentials) based on the limited info given and we identify all the gaps in our learning, go off and research those things then return 3 days later to have more of the case unfold.

    When we do the ‘report back’ we teach each other what we’ve learned. Our tutor (an MD) asks us questions and when we want to order tests we have to give reasons for each one and then also predict what the tests will show–AND how a test would change our management of the case. And we are given further info based on our questions/tests.

    I think it is a genius way of getting medical students to think along these lines from the beginning (and as a former RN its nice to know that docs from a program like this will be less likely to do the shotgun approach as it is really beaten out of us in PBL).

    Thanks for this post!

    (Oh and yes we DO have biochem, histology, physiology, anatomy lectures etc…so don’t worry that it’s all a self taught program!!) :)

  23. “Until we address the fear of malpractice that drives defensive medicine (and I’ll even cede that some of that fear is irrational), we’ll never reduce our healthcare spending.”

    Very true (although it’s unlikely healthcare spending will be reduced regardless). But since we’ve tried your initial solutions on reducing defensive medicine via tort reform, and that clearly hasn’t worked, perhaps it’s time to address defensive medicine from the medical side? Maybe promulgate standards of care which physicians can agree on and adopt for X,Y, and Z situations?

  24. As one of my med school professors used to say: When all else fails, examine the patient.
    Excellent post!

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