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Misdiagnosed
39 Plays3 hours ago
In this episode, Miranda and Josh discuss a few interesting cases that were initially misdiagnosed and explore how the correct diagnosis was eventually identified. They break down the clinical reasoning process, share key examination findings, and discuss lessons learned along the way. This conversation offers practical insights that can help clinicians think critically when a patient's presentation doesn't quite fit the expected diagnosis.
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Transcript
Introduction to Ham Therapy Academy
00:00:05
josh MacDonald
Hi, I'm Josh McDonald.
00:00:06
Miranda Materi
And I'm Miranda Matieri and we are Ham Therapy Academy.
00:00:10
josh MacDonald
We're going to talk today about how we as therapists have the opportunity to sometimes catch things that might go missed by other providers or sometimes kind of fill in the gaps where people may fall in those gaps because we're paying attention and doing due diligence.
Role of Therapists in Medical Diagnostics
00:00:24
josh MacDonald
And so we have a couple of little quick case studies. Rhonda, don't you talk about one of your therapists and what she caught?
00:00:28
Miranda Materi
Yeah. So before I do that real quickly, I want to say too that as therapists, we have the opportunity to spend a lot of time with our patients, right? So we're seeing them two or three times a week for an hour at a time where versus the physician doing some diagnostics may only be with them for like 10 minutes. So just to add that in is like, we know that we have an advantage in sometimes finding these case situations and um maybe saying that, oh, that's probably not quite the right diagnosis.
Case Study: Allison's Discovery
00:00:56
Miranda Materi
So this particular case that one of my therapists caught was with a patient.
00:01:01
Miranda Materi
It was actually a work comp patient and he had a fall from, i don't remember how many feet it was, but he landed on both arms and he first had kind of like this weird like numbness and tingling in both hands through his small and ring finger. So they went in and did an older nerve transposition, kind of got a little better, and then he started to having median nerve problems. So they went and a median nerve release, you know, at the carpal tunnel inlet, and then he was still having symptoms. So they went a little more proximal and did a release at the bicepinal apneurosis, still having problems. um
00:01:39
Miranda Materi
And you know, at this point, Alison's like, you know, we need to start doing some other testing. So she moved a little proximal and started doing some of the screenings for a thoracic outlet and basically just went through the list of tests, said, this is what you're testing positive for, um sent a note to the doctor and the doctor ended up referring or the hand surgeon ended up referring him to a partner in his practice who treated thoracic outlet. And then the treatment that they did was they actually put Botox in his scalenes and in his pec minor, more of a, as like a diagnostic. And I know sometimes they'll do like a light or I'm not quite sure what kind of paralytic they do to block it, but they'll do another one as well. And basically if they have some relief, then they know that, oh yeah, we're kind of on the right track. So this patient immediately felt better after having those injections. And then he went on for conservative treatment and is actually doing much better. So.
00:02:36
josh MacDonald
That's great. and And it's easy to kind of, i don't want to say point fingers, but like, how did the others miss this? How did no one catch this? But we've all done that where we're chasing down one pathway and we miss a sign. We miss something that someone else catches. Maybe it's a coverage therapist. So um great for Allison for catching that in and being able to realize, hey, there's some greater symptoms here. And then knowing the provocative tests to kind of go through to find that diagnosis and kind of pull a whole bunch of information together when maybe everyone else was just kind of seeing splinters of things.
00:03:06
Miranda Materi
Right. When we're seeing a patient post-op, you know, for an ulnar nerve transposition, that's kind of what you're focused on, right? And you're not thinking at this point in time, we need to do this upper quadrant screening, right? You're thinking, okay, I'm going to do um what we typically do for cubicle tunnel. So i think sometimes it's just, you know, getting fresh eyes, like you said, or having someone else referring in or filling in, seeing something that you might've missed.
00:03:30
josh MacDonald
Yeah, yeah.
Case Study: Emily's Advocacy
00:03:31
josh MacDonald
um We had a similar kind of situation. a therapist of ours, Emily, was treating, it was kind of a new eval, and this person came in and it was a mid-shaft humeral fracture. And you you just get this diagnosis. You don't really know what to expect. This patient came in with significant swelling and ah kind of ah a cavity of wound within this edema that was that was also draining some purulent fluid, some white drainage, kind of smelled a little bad. So she reached out to the PA that referred the PA said, yeah, yeah, yeah. Wound care knows.
00:04:04
josh MacDonald
They're just kind of tracking it. Let's go ahead and just and just do a splint to stabilize the humerus. And she said, this just doesn't seem right. So she sent her across the street to the ah ER. And a lot of times we get the information from a PA or a doctor, and we just kind of out of defensiveness say like, okay, I'm just going to do what they suggested. And then it's not on me. She went ahead and said, don't you go across the street to the ah ER and and have it checked out? And sure enough, she had a new infection that no one else had seen or realized or caught that other providers, multiples had said like, just hang on, just wait, but they didn't have a chance to see eyes on because they had been doing this one month checkup thing and seeing them periodically. But now that she was in front of a new person, she really had the the appropriate self-confidence to say, you know, I just don't trust this. And I'd rather be wrong on the side of sending her unnecessarily than not sending her. And this goes septic or something.
00:04:58
Miranda Materi
Right. Yeah, that's definitely the case. And I think sometimes, or actually I know this because I was reading a study on it. They were saying the more years you have in practice and in clinical experience, the more confident you are in directing your patient, even though it might be going against, you know, what they've been told by their surgeon or their physician. I think you kind of get a sense to know this doesn't seem quite right. I've seen hundreds of these and they never present quite like this.
00:05:24
josh MacDonald
Yeah, yeah. um and That's interesting. On the flip side, not based on any evidence, I do find too that my new grad therapists, the one that have the ones that have that healthy respect of what they don't know yet, you know we all have some new grads or students who are maybe a little overly confident, but a lot of my students have an appropriate, like, let's question everything and let's second guess everything.
00:05:45
josh MacDonald
And another therapist who a patient came in, they had some of the diagnosis, they went, oh, I was playing softball and jammed my finger.
00:05:45
Miranda Materi
Yeah.
00:05:52
josh MacDonald
He says, you know what, let me take a closer look at that. It just looked like swelling. Turns out she had had a central slip rupture and and we were able to get her moving on on the on the care for that. So sometimes those newer therapists have that, like, you know, let's let's double check and confirm where maybe as an older therapist, I'm just kind of cruising along like, well, we're just here to see you for this.
00:06:09
josh MacDonald
And that was just like swelling. So maybe I'm not second guessing things as much as I should sometimes.
00:06:14
Miranda Materi
Oh yeah, that's true too. That's a different way to look at it.
00:06:17
josh MacDonald
Yeah. Yeah.
Empowering Patient Decision-Making
00:06:18
josh MacDonald
But I think you're right in the, like when you said at the beginning, it has, it has a lot to do with how much time we spend with patients also. Like we see them way more hours, way more frequently. And I know a lot of times patients will say like, i don't know if I need more therapy. I'll wait to see what the doctor says.
00:06:34
josh MacDonald
And I try to empower patients. Like you get to choose, like you're the consumer. If you feel like this is useful or not, you should have the say in that. Don't just trust what any one of us medical professionals pushes towards you.
00:06:46
josh MacDonald
Um, But but be an advocate for yourself and chase down these other diagnoses like, you know what, this system doesn't sound right. And it's just procedure at one after the next. Let's make sure this fits what you're going through.
00:06:58
Miranda Materi
Yeah, that's an interesting point I think you bring up. And I think there's a lot of like health literacy and things like that. Like I think about my brother who's always been in rural Wyoming and, you know, hasn't had to ever have medical care. And, i you know, I've been with him at these appointments because he's been, you know, kind of going through this illness. And you know, i'm kind of like, why is he just like not asking questions or wondering, like, when should I make my next like, he has no idea.
00:07:22
Miranda Materi
And he's a smart guy.
00:07:22
josh MacDonald
Yeah.
00:07:23
Miranda Materi
But you know, they just, I feel like patients don't know. So I think your suggestion of empowering our patients to ask questions and, and to be an advocate for themselves has, you know, really powerful.
00:07:35
josh MacDonald
Yeah. Yeah.
Therapists' Unique Advantages
00:07:36
josh MacDonald
Send your patients in with the list of questions or, you know, give them the idea that the awareness that you're the consumer in this. And if your mechanic wasn't explaining things to you, you wouldn't stay with them. If they were just telling you, dictating what was going to happen, same thing. Don't just let let us as providers and I include us as therapists tell you like this is exactly what you should be doing and and to not tolerate questions and and follow up.
00:07:59
Miranda Materi
Yeah, and I often think like how many times do patients say, oh, my, you know, my doctor said I need this surgery and it's going to make it better, but really just kind of going like, oh, I guess I do need the surgery and I'm going to do it even though, you know, some of my symptoms don't match what he's telling me. Yeah.
00:08:13
josh MacDonald
Yeah, yeah, yeah. Or I don't really think I wanted surgery, but this is the next thing. So we're doing this because the the thought is this person's the expert. And and we as therapists sometimes have an opportunity to have a deeper conversation that's more than the three to four minutes doctors are kind of allowed to spend with patients. So it's an opportunity for us to get a little deeper into what do you want to do? What's your goal in all of this? Is it just to get back to life or is it to be 100 percent or what's your goal?
00:08:40
Miranda Materi
Yeah, definitely. And I think it's just we have really a great advantage.
00:08:41
josh MacDonald
Yeah.
00:08:44
Miranda Materi
We have all this time and sometimes surgeons and physicians don't have that time that that we're lucky to have with our patients.
00:08:51
josh MacDonald
Yeah, yeah, that's great.
Conclusion and Listener Engagement
00:08:53
josh MacDonald
Well, hopefully this is helpful. Maybe you've got some situations where you and your staff have been able to kind of catch some things that other people missed. But it's a good reminder to always stay diligent as we're spending time with our patients not get stuck on one pathway, but make sure we're kind of evaluating the whole person and seeing them globally as ah as a ah whole person, not just the diagnosis code.
00:09:13
Miranda Materi
Yeah. So if you have information you want to share, reach out to us, info at Ham Therapy Academy.