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Reevaluating Prior Clinical Impressions
ISSUE: When is it necessary and appropriate to reevaluate diagnostic choices?
Twin A was one of monoamniotic twins born at 37 weeks. Prior to discharge from the hospital, thyroid testing was performed and was reported as "normal" for both infants.
At the six-week baby checkup, the family physician did not note any abnormalities in twin A. When the baby was between five and eight months of age, her parents told the family physician that she "wasn't trying to sit up and was very pale." The parents did comment that this was the "good" twin because she slept through the night and rarely cried. The physician reassured the parents that the baby's behaviors were normal. At 10 months of age, the mother asked for a "complete physical" because of twin A's lack of growth. The physician recorded the baby's height and weight on a growth chart and referred the child to a pediatrician, who attributed the growth lag to Twin B being a better feeder. The pediatrician diagnosed iron deficiency anemia and prescribed oral iron.
Six weeks later, the baby's hemoglobin rose from 8.8 to 9.0. By the next visit three months later, her levels had dropped to 8.6. The pediatrician assumed that the baby was not adequately absorbing iron and administered iron injections on subsequent visits. By 14 months of age, the baby's hemoglobin had only risen to 9.9. The pediatrician told the mother that the hemoglobin would eventually return to normal and that further tests were unnecessary.
At 16 months of age, a different pediatrician diagnosed the baby's condition as congenital hypothyroidism. The baby subsequently underwent thyroid-replacement therapy that restored normal physical development, but could not completely restore mental development. As a result, twin A experienced permanent cognitive impairments and was unable to live independently.
Twin A was one of monoamniotic twins born at 37 weeks. Prior to discharge from the hospital, thyroid testing was performed and was reported as "normal" for both infants.
At the six-week baby checkup, the family physician did not note any abnormalities in twin A. When the baby was between five and eight months of age, her parents told the family physician that she "wasn't trying to sit up and was very pale." The parents did comment that this was the "good" twin because she slept through the night and rarely cried. The physician reassured the parents that the baby's behaviors were normal. At 10 months of age, the mother asked for a "complete physical" because of twin A's lack of growth. The physician recorded the baby's height and weight on a growth chart and referred the child to a pediatrician, who attributed the growth lag to Twin B being a better feeder. The pediatrician diagnosed iron deficiency anemia and prescribed oral iron.
Six weeks later, the baby's hemoglobin rose from 8.8 to 9.0. By the next visit three months later, her levels had dropped to 8.6. The pediatrician assumed that the baby was not adequately absorbing iron and administered iron injections on subsequent visits. By 14 months of age, the baby's hemoglobin had only risen to 9.9. The pediatrician told the mother that the hemoglobin would eventually return to normal and that further tests were unnecessary.
At 16 months of age, a different pediatrician diagnosed the baby's condition as congenital hypothyroidism. The baby subsequently underwent thyroid-replacement therapy that restored normal physical development, but could not completely restore mental development. As a result, twin A experienced permanent cognitive impairments and was unable to live independently.
From your analysis of the case, assess whether the following statesments are true or false:
| * | A physician should rely on the results of customary diagnostic tests, even if they are inconsistent with the patient's clinical presentation. | True or False |
| * | A physician's care is substandard if he/she does not make an effort to detect a condition requiring timely management. | True or False |
| * | A physician relying upon test results for diagnosis or treatment should be familiar with clinical circumstances that can affect the accuracy of the test results. | True or False |
Expand to check answers
GENERAL PRINCIPLE: A physician is expected to use customary diagnostic guidelines to detect and rule out conditions that require timely treatment to avoid irreversible damage.
APPLIED PRINCIPLE: Although twin A did not manifest many of the classic stigmata of congenital hypothyroidism, she did exhibit retarded growth and development, decreased activity and refractory anemia. Maintaining a growth chart would have likely confirmed a growth deficiency earlier, especially with the other twin for comparison. This would have prompted an investigation for the cause of the deficiency, including tests to detect thyroid deficiency before the occurrence of harmful and irreversible effects on the child's mental development. Either the physicians failed to properly keep the chart or did not properly interpret its significance.
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APPLIED PRINCIPLE: Although twin A did not manifest many of the classic stigmata of congenital hypothyroidism, she did exhibit retarded growth and development, decreased activity and refractory anemia. Maintaining a growth chart would have likely confirmed a growth deficiency earlier, especially with the other twin for comparison. This would have prompted an investigation for the cause of the deficiency, including tests to detect thyroid deficiency before the occurrence of harmful and irreversible effects on the child's mental development. Either the physicians failed to properly keep the chart or did not properly interpret its significance.
| * | A physician should rely on the results of customary diagnostic tests, even if they are inconsistent with the patient's clinical presentation. | False |
| * | A physician's care is substandard if he/she does not make an effort to detect a condition requiring timely management. | True |
| * | A physician relying upon test results for diagnosis or treatment should be familiar with clinical circumstances that can affect the accuracy of the test results. | True |