Diagnosing Without a Safety Net

Did you hear about the dermatologist who did an emergency tracheostomy on an airplane? What would have been really impressive is an emergency department doctor doing a punch biopsy at 30,000 feet. Jokes aside, certain procedures and diagnostic tools, as simple as they are to perform, can be surprisingly inaccessible to some patient populations.

“Insert Superlative Adjective Here” Dermatology in Suburbanville, America, will have a plethora of diagnostic tools available. But what about an inner-city urgent care clinic? Or a rural office that takes a month for biopsy results turnaround and has a high percentage of patients lost to follow-up? Or a mobile practice that can't fit a microscope into their suitcases? The list goes on: a patient who cannot undergo a biopsy because they are too anxious, are older, or have an intellectual disability or a patient who only reaches out via telemedicine and can't get an appointment with the dermatologist's office for 4 months. These are all very real scenarios that each present diagnostic challenges.

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Clinical Examination

In these situations, maximizing every resource at your disposal is key and truly leans into your clinical diagnosis skills. Beyond using a handheld dermatoscope or Wood lamp, you want to be palpating, comparing, and asking for a complete history on the lesion or rash at hand. Go back to the “OPQRST” method many of us learned at school¹:

O (onset): When did it start?

P (provocation/palliation): What makes it better? What makes it worse?

Q (quality): What does it feel like?

R (region): Where is the condition located?

S (severity): How bad is the condition on a scale from 1 to 10?

T (timing): How long has the condition been going on? Is it better, worse, or the same over time?

Going back to the age-old skills of clinical diagnosis, a patient and keen ear for the patient’s history as well as a deep knowledge of not only the most common presentation of the condition but also its not-to-be-missed variants are essential for these environments.

Task Shifting

Now, even the most astute observational clinician can be fooled by notoriously evasive diagnoses such as scabies, syphilis, or cutaneous lymphoma. In these cases, it is essential to practice task shifting. Identify the key players in this patient’s environment and train them to recognize the red flags to seek follow-up care. At the very least, show them what to track so they can report back by the next appointment. They could report whether the rash improved with treatment or worsened, and they could bring up the condition with other health care personnel to close the loop of a multisystem disorder. This also ensures that the patient attends follow-up. In addition, establishing contact with the patient’s medical team goes a long way to establishing trust. The use of telemedicine, although limited, can go a long way to observing the condition’s evolution over time if the patient cannot attend an in-person follow-up.

Get Everyone on the Same Page

In addition, community-wide approaches for infection are particularly helpful in cases of congregate care. The most common example is scabies cases in nursing homes. If one positive case is identified via biopsy results, local state policies mandate treatment of not only the entire floor of residents but the staff as well. If a syphilis case is identified, clinicians are mandatory reporters to ensure contact tracing, treatment of partners, and identification of health trends.²

The Algorithm Is on Your Side

The development of clear and simple treatment algorithms is key to identifying a condition without diagnostic tools. For this, classification of the lesion is the way to go. Is the rash palpable? Is it scaling or crusting? Is it itchy or painful? Is it nodular or ill-defined plaques? Does the patient have a toxic appearance? Many leading internal medicine and dermatologic institutions have developed algorithmic charts that come quite in handy for narrowing down a diagnosis just from physical examination.

Talk to Each Other

One of the most important concepts to keep in mind is managing expectations, and this includes both the patient and the clinical staff as well. Building a trusting relationship with clinical staff and explaining your reasoning, your backup plan, and alarm symptoms are essential. This means the staff will bear with you and encourage the patient to have patience while you wrestle to get to the bottom of this tricky condition. This means that the nursing staff and primary care provider will be empowered to continue their care and treat the patient while assessing for a clinical response.

Although diagnostic tools explode in variety and accuracy, access remains a challenge for many. Brushing up on our clinical diagnosis and systems-based approach will be instrumental in making sure these patients don’t fall through the cracks.

References

1. Lacasse M, Maker D. Fishing and history taking: from the net to the line. Can Fam Physician. 2008;54(6):891-892.
2. St Lawrence JS, Montaño DE, Kasprzyk D, Phillips WR, Armstrong K, Leichliter JS. STD screening, testing, case reporting, and clinical and partner notification practices: a national survey of US physicians. Am J Public Health. 2002;92(11):1784-1788. doi:10.2105/ajph.92.11.1784